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ROENTGEN  INTERPRETATIOX 


A  MANUAL 


FOR  STUDENTS  AND  PRACTITIONERS 


BY 


GEORGE  W.  HOLMES,  M.D. 

nOENTGEXOLOGIST    TO    THE    MASSACHUSETTS    GENERAL    HOSPITAL    AND    INSTRUCTOR 
IN    ROENTGENOLOGY,    HARVARD    MEDICAL    SCHOOL 


HOWARD  E.  RUGGLES,  M.D. 

ROENTGENOLOGIST     TO     THE     UNIVERSITY    OF     CALIFORNLA.     HOSPITAL     AND     CLINICAL 
PROFESSOR    OF   ROENTGENOLOGY,   UNIVERSITY   OF   CALIFORNIA  MEDICAL   SCHOOL 


ILLUSTRATED  WITH    181    ENGRAVINGS 


LEA   &   FEBIGER 

PHILADELPHIA   AND   NEW   YORK 


Copyright 

LEA   &   FEBIGER 

1919 


W  ^  - 


DEDICATED  TO 

WALTER  J.   DODD,   M.D. 

PIONEER  IN  EOENTGENOLOGY 

AND 

MARTYR  TO  HUMANITY 


PEEFACE. 


It  is  hoped  that  this  book  will  prove  of  practical  aid  to  those 
in  search  of  a  working  knowledge  of  roentgen  interpretation.  The 
intention  has  been  to  present  the  essentials  in  a  comp^ehensi^'e 
form.  More  detailed  information  may  be  secured  through  the 
references  to  the  recent  literature,  which  will  be  found  at  the  end 
of  the  chapters. 

The  illustrations  have  been  chosen  as  types  of  lesions,  or  as 
momentary  phases  of  constantly  changing  and  extremely  variable 
processes.  The  beginner  should  not  attempt  to  make  diagnoses 
from  them  by  comparison  with  his  own  plates. 

The  necessity  of  a  medical  training  as  a  prerequisite  in  this  field 
is,  of  course,  recognized,  but  the  particular  importance  of  thorough 
grounding  in  pathology  is  not  always  sufficiently  plain.  In  attempt- 
ing to  study  gross  changes  by  means  of  shadows,  a  knowledge  of 
pathology  is  as  essential  to  the  roentgenologist  as  anatomy  to  the 
surgeon.  G.  W.  H. 

H.  E.  R. 

Boston,  1919. 


CONTEXTS. 


Introduction -.      ,      .      .       17 

CHAPTER    I. 
CoxFrsrs'G  Shadow's  an"d  Aetefacts 19 

CHAPTER    n. 

AnATOMIC.U.    V.IEIATIOXS    AND    DE^"ELOPilEXT 26 

CHAPTER    in. 
Feactitres  an'd  Dislocations 33 

CH.\PTER   IV. 
BoxE  Pathology 50 

CHAPTER   y. 
Skull 83 

CHAPTER   VI. 

JOES'TP,  TeXDOXS   -IND    BuHS-E 97 

CHAPTER   VII. 
The  Chest Ill 

CHAPTER    VIII. 
Ga-steo-lntestixal  Teact 151 

CHAPTER    IX. 
Gexito-ueix.\et  Teact 191 


EOENTGEN  INTERPRETATION. 


INTRODUCTION. 

It  cannot  be  too  strongly  emphasized  in  the  begmning  that 
roentgen  images  are  shadowgraphs;  that  they  are  the  record  of  the 
varying  opacities  through  which  a  bundle  of  rays  has  passed; 
and  that  they  are  subject  to  the  possibilit}'  of  erroneous  deductions 
consequent  upon  the  fact  that  they  are  shadows.  Objects  are  visible 
when  they  differ  in  density  from  their  surroundings.  The  outline 
of  the  heart  is  distinct  against  the  air-filled  lung  about  it  while  the 
uterus  of  similar  density  is  lost  in  the  shadow  of  the  pelvis. 

Furthermore,  the  roentgenogram  is  a  projection  on  a  flat  surface 
of  everything  in  every  plane  between  the  plate  and  the  tube's  target. 
It  must  not  be  forgotten  that  in  addition  to  the  patient  this  includes 
opaque  objects  upon  the  filters,  the  clothing  of  the  patient  and  the 
envelope  of  the  plate.  The  shadow  of  a  rounded  bone  with  ridges 
on  opposite  sides  will  appear  on  the  plate  as  a  flat  image  with  the 
ridges  lying  side  by  side.  It  is  therefore  essential  for  the  roentgen- 
ologist to  have  a  thorough  knowledge  of  the  projected  appearance  of 
anatomical  structures,  so  that  he  may  be  able  to  visualize  from  a 
flat  plate  the  relative  depth  of  objects  seen  upon  it.  The  study  of 
stereoscopic  plates  is  of  great  value  in  this  connection. 

Another  source  of  possible  error  lies  in  the  fact  that  we  commonly 
employ  divergent  rays.  Parallel  rays  are  seldom  made  use  of  in 
roentgenology  except  in  determinations  of  the  size  of  the  heart. 
Ordinarily  plates  are  produced  by  a  tube  which  is  relatively  close 
to  the  plate;  therefore  we  are  using  divergent  rsiys,  and  the  images 
of  objects  in  their  path  will  be  distorted  according  to  their  position 
with  reference  to  the  plate.  Objects  in  contact  with  the  plate  give 
an  image  of  actual  size  and  are  sharply  outlined.  As  they  recede 
from  it  their  outline  becomes  more  hazy  and  their  size  increases. 
When  a  wide  field  of  illumination  is  employed  the  central  rays  are 
practically  parallel,  but  at  the  margins  of  the  field  they  strike 
2     . 


18  INTRODUCTION 

obliquely,  giving  a  markedly  distorted  image.  It  is  customary, 
therefore,  to  limit  the  rays  as  much  as  possible  to  the  central  bundle 
by  the  use  of  diaphragms  and  to  place  the  area  under  observation 
as  closely  as  possible  to  the  plate.  There  is  an  additional  advantage 
to  be  gained  in  the  employment  of  small  diaphragms  because  the 
plates  are  brighter.  Anything  in  the  path  of  the  rays  gives  off 
secondary  radiation  and  scatters  the  primary  beam  just  as  light  is 
scattered  by  fog.  This  secondary  and  scattered  radiation  tends  to 
obscure  the  image  cast  by  the  primary  rays,  therefore  the  area  of 
tissue  exposed  to  the  rays  should  be  as  limited  as  possible. 

One  view  is  an  isolated  observation  and  is  perhaps  less  to  be 
relied  upon  than  a  single  observation  in  any  field  of  medicine.  As 
far  as  possible,  plates  should  always  be  secured  in  planes  at  right 
angles  to  each  other,  and  often  additional  plates  at  various  angles 
will  establish  a  diagnosis  which  would  otherwise  be  impossible. 
This  is  particularly  important  in  studies  of  the  skull,  spine  and 
the  neighborhood  of  joints. 

In  conclusion,  there  are  several  axioms  which  form  the  basis  for 
successful  roentgen  interpretation: 

1.  Do  not  attempt  to  include  e^'ery thing  on  one  plate;  several 
small  ones  are  always  preferable. 

2.  Do  not  make  a  diagnosis  before  everything  possible  has  been 
done;    thoroughness  is  essential. 

3.  Be  familiar  with  the  projected  appearance  of  normal  structures. 

4.  Use  routine  positions  for  all  examinations  as  far  as  possible. 

5.  Do  not  give  opinions  on  poor  plates. 

In  order  to  avoid  confusion  in  the  use  of  the  terms  "increased"  and 
"diminished"  density,  it  should  be  understood  that  when  they  occur 
in  this  text  they  apply  to  the  tissues  of  the  patient.  These  expres- 
sions may  be  employed  to  designate  the  thickness  of  the  silver 
deposit  on  the  roentgenogram — the  actual  density  in  the  image  of 
the  emulsion — which  necessaril}'  is  reciprocal  to  the  density  of  the 
patient.  So,  in  this  book,  "increased  density"  means  the  loss  of  trans- 
parency to  the  rays  and  light  areas  on  the  roentgenogram.  Dimin- 
ished density  means  increased  radiability  and  darkening  of  the 
plate.  Most  of  the  illustrations  are  positives  of  the  original  roentgen 
negatives  and  therefore  their  values  are  the  opposites  of  those  in 
the  plates. 


CHAPTER   I. 
CONFUSING  SHADOWS  AND  ARTEFACTS. 

There  are  many  shadows  in  normal  plates  which  ma}'  cause 
errors  in  interpretation.  Their  significance  is  obvious  when  they 
have  once  been  recognized,  but  the  beginner  is  prone  to  attach 
undue  importance  to  them,  particularly  when  they  occur  in  regions 
to  which  his  attention  has  been  directed  by  the  clinical  picture. 
In  case  of  doubt  it  is  always  wise  to  take  plates  of  the  corresponding 
parts  or  to  compare  them  with  other  plates  of  the  same  region  in 
other  individuals. 

Lines  Mistaken  for  Fractures.^ — The  most  common  error  here  occurs 
with  the  epiphyseal  lines,  which  appear  as  a  definite  break  in  the 
continuity  of  the  bones.  It  is  therefore  essential  for  the  roentgen- 
ologist to  have  a  complete  knowledge  of  the  time  of  appearance  of 
the, various  centers  of  ossification,  the  location  of  epiphyseal  lines 
and  the  approximate  age  at  which  they  disappear. 

When  one  bone  overlaps  another  or  the  edge  of  a  muscle  bundle 
crosses  a  bone  there  may  be  a  thin,  sharply  drawn  black  line  which 
at  times  resembles  a  fracture.  This  appearance  is  often  noticed  in 
the  trans^'erse  process  of  the  lumbar  ^-ertebrse  where  the  inner 
margin  of  the  psoas  muscle  crosses  them. 

A  third  possibility  of  error  is  furnished  by  the  markings  due  to 
bloodvessels  which  are  particularly  evident  in  the  skull  where  the 
course  of  the  middle  meningeal  artery  appears  as  a  tortuous  groove 
behind  the  coronal  suture  and  is  more  or  less  sharply  outlined. 
The  venous  channels  in  the  diploe  of  the  skull  provide  another  s;et 
of  dark  lines,  irregular  in  their  course  and  indefinite  in  outline.^ 
In  the  long  bones  there  is  ordinarily  a  definite  groove  where  the 
nutrient  artery  enters  the  shaft,  which  may  be  mistaken  for  a 
fracture  when  seen  in  profile,  as,  for  example,  in  the  phalanges  of 
the  hands  and  feet.  It  is  well,  therefore,  to  be  familiar  with  the 
anatomy  of  these  vessels. 

An  accurate  knowledge  of  the  location  and  appearance  of  the 
sutures  of  the  skull  will  prevent  their  misinterpretation,  a  common 


20  CONFUSING  SHADOWS  AND  ARTEFACTS 

error  particularly  with  the  parietomastoid,  which  is  often  called  a 
fracture  of  the  base. 

The  characteristics  of  a  fracture  line  which  are  usually  sufficient 
to  identify  it  are  that  it  is  a  dense  black  with  sharply  cut  margins; 
its  course  is  usually  irregular  and,  particularly  in  the  skull,  at  vari- 
ance with  that  of  the  bloodvessel  markings. 

Roughening  of  the  Margins  of  Bones  Mistaken  for  Periostitis. — 
Frequently  there  is  a  thin  plate  of  boiie  extenduig  out  on  the  inter- 
muscular septum,  as,  for  example,  between  the  tibia  and  fibula, 
or  radius  and  ulna,  which  seen  in  profile  is  quite  suggestive  of  peri- 
osteal proliferation,  and  one  must  be  careful  to  differentiate  this 
condition  from  a  true  periostitis. 

A  similar  process  is  liable  to  occur  at  the  attachment  of  tendons, 
such  as  the  tendo  Achillis,  the  triceps,  along  the  margin  of  the  iliac 
crests,  along  the  linea  aspera  of  the  femur  and  about  the  external 
occipital  protuberances  of  the  skull.  There  is  very  commonly  a 
roughening  and  slight  proliferation  along  the  margins  of  the  pha- 
langes of  the  hands,  which  is  without  significance.  The  flange  behind 
the  intercostal  groove  on  the  inferior  margin  of  the  ribs  posteriorly 
is  often  exaggerated  and  suggests  a  periostitis.  The  tibial  tubercle 
may  be  somewhat  widened  and  its  lateral  margin  projected  outside 
the  outer  border  of  the  tibia  a  short  distance  below  the  head;  it 
is  frequently  mistaken  for  a  localized  proliferation  of  periosteum. 
There  is  normally  a  variable  amount  of  roughening  on  the  inferior 
margin  of  the  pubes  and  ischial  tuberosities. 

A  true  periostitis  consists  of  more  or  less  extensive  deposit  of  new 
bone  upon  a  normal  appearing  cortex.  This  deposit  may  be  laid 
down  in  multiple  thin  lamellae,  giving  it  a  delicately  stratified  struc- 
ture, which  is  a  form  frequently  seen  in  lues;  or  it  may  be  a  low 
irregular  fringe,  as  seen  in  some  forms  of  osteomyelitis. 

Calcifications. — Calcium  salts  cast  a  dense  shadow  wherever  they 
occur.  They  have  an  extensive  distribution  in  the  body  outside  of 
the  bony  structures.  Cartilage  is  perhaps  the  tissue  in  which  cal- 
cium salts  are  most  prone  to  be  deposited.  This  is  seen  in  the  costal 
cartilages,  where  the  deposit  usually  occurs  upon  the  surface  of  the 
cartilage  in  the  form  of  irregular  plaques  appearing  in  the  chest, 
spine,  gall-bladder  and  kidney  plates.  These  shadows  are  without 
significance  and  their  nature  is,  as  a  rule,  easily  determined. 

Calcification  also  occurs  in  the  same  manner  in  the  cartilages  of 
the  larynx  and  is  easily  recognizable  in  lateral  views  of  the  neck. 
In  anteroposterior  views  of  this  region,  however,  they  are  projected 


CALCIFICATIONS  21 

in  the  region  of  the  lateral  masses  of  the  cervical  vertebrse  and  have 
been  mistaken  for  hypertrophic  changes  in  the  spine  or  calcified 
vertebral  arteries. 

Another  common  seat  of  calcification  is  old  tuberculous  foci, 
examples  of  which  are  the  irregular  masses  in  bronchial  glands,  the 
characteristic  agglomerations  of  small  masses  which  produce  the 
irregular  mulberry-like  shadows  typical  of  tuberculous  glands,  which 


Fig    1 . — Calcified  retroperitoneal  gland  suggesting  gall-stones. 

are  frequently  found  in  the  neck  and  throughout  the  mesentery  in 
the  abdomen.  They  are  usually  multiple.  Small,  rounded,  dense 
masses  sometimes  occur  scattered  throughout  the  spleen  and  may 
occur  anywhere  beneath  the  peritoneum  as  the  end-result  of  localized 
tuberculous  processes.  An  extensive  calcification  is  sometimes 
encountered  in  tuberculous  kidneys.  Extensive  sheets  of  calcifica- 
tion are  sometimes  seen  in  the  pleura  and  very  rarely  in  the  peri- 
cardium following  tuberculous  infection. 


22  CONFUSING  SHADOWS  AND  ARTEFACTS 

The  calcification  which  occurs  in  arterial  walls  as  a  result  of 
arteriosclerosis  is  a  familiar  picture.  It  may  be  found  in  the  course 
of  any  of  the  arteries,  and  is  sometimes  extensive  and  striking. 
The  age  of  the  patient  must  always  be  taken  into  consideration 
in  estimating  its  proper  significance.  When  it  occurs  in  a  young 
patient  it  is  most  commonly  the  result  of  lues.  These  changes  in 
the  internal  iliac  arteries  may  be  mistaken  for  stone  in  the  ureter. 

Calcification  appears  in  veins  most  frequently  in  the  form  of 
small,  rounded,  dense  masses,  so-called  phleboliths,  seen  in  the 
pelvis  and  in  the  region  of  the  ischial  spines;  they  represent  small 
calcified  thrombi  on  the  distal  side  of  the  valves,  and  must  not  be 
mistaken  for  ureteral  stones.  Rarely,  calcification  similar  to  that 
seen  in  arteriosclerosis  may  be  evident  in  old  varicose  veins. 

Extensive  calcification  may  occur  in  hematomata;  this  is  most 
commonly  seen  about  the  elbow  and  in  the  quadriceps  extensor. 
It  may  develop  rather  suddenly  several  weeks  after  an  injury  and 
present  an  appearance  on  the  plate  which  resembles  periosteal  sarcoma. 

Definite  irregular  deposits  of  calcium  salts  may  be  found  about 
foreign  bodies,  such  as  silk  sutures,  and  the  cysts  of  parasites. 
Coming  under  this  head  may  be  mentioned  calcified  pineal  glands 
which  are  fairly  common  and  the  rare  cases  of  calcification  within 
a  dead  fetus. 

Calcification  is  fairly  common  in  tumor  masses  whose  blood  supply 
has  been  obliterated,  of  which  an  ordinary  example  is  that  seen  in 
uterine  fibroids.  It  is  encountered  also  in  other  slow-growing  and 
benign  tumors  of  the  connective-tissue  group,  such  as  fibromata 
and  lipomata.  It  occurs  in  certain  slowly  growing  scirrhous  carci- 
nomata  and  has  been  noted  in  some  tumors  in  the  pancreas  and 
gall-bladder  as  well  as  in  glandular  metastases.  Angiomata  may 
contain  round  cyst-like  masses  of  varying  size,  representing  calci- 
fied thrombi,  and  endotheliomata  frequently  contain  irregular  dense 
areas,  as,  for  example,  in  psammomata  in  the  skull. 

Ovaries  are  sometimes  the  site  of  calcification,  in  which  case  they 
appear  as  flat  oval  masses  resembling  glands  in  the  lateral  portions 
of  the  pelvis. 

Mention  must  also  be  made  of  the  fact  that  infarcts  of  any  of  the 
viscera  may  subsequently  calcify.  Another  rare  condition  is  the 
so-called  calcareous  metastasis  in  which  in  extreme  resorption  of 
bone  from  extensive  caries,  malignant  disease,  etc.,  a  widespread 
deposit  of  calcium  salts  may  occur  in  the  cartilages,  mucous  mem- 
branes of  the  mouth,  stomach  and  arteries. 


AREAS  OF  INCREASED  DENSITY  IN  SPONGY  BONE       23 

Areas  of  Increased  Density  in  Spongy  Bone. — Small  round  areas 
of  condensation  are  sometimes  seen  in  cancellous  bone.  There  is 
no  disturbance  in  the  normal  structure  of  the  bone  about  them, 
and  their  significance  has  been  a  matter  of  considerable  speculation. 
They  may  represent  old  healed  areas  of  infection  or  some  localized 


Fig. 


-Foreign  body  in  soft  tissues.      (Metallic  injection.) 


disturbance  in  the  growth  of  the  bone.  At  any  rate,  they  have  no 
pathological  importance.  They  may  occur  near  the  ends  of  long 
bones  in  the  carpus,  tarsus  or  within  any  of  the  flat  bones.  The 
transverse  dense  lines,  often  multiple,  which  occur  along  the  medullary 
canal  toward  the  end  of  the  long  bones,  are  the  result  of  disturbances 
of  growth  which  occurred  at  the  time  when  the  epiphyseal  line  was 


24  CONFUSING  SHADOWS  AND  ARTEFACTS 

at  that  point;    they  may  be  hkened  to  the  growth  of  rings  In  the 
trunk  of  a  tree. 

Warts  and  Fibromata  on  the  Skin. — Any  area  of  skin  which  presses 
heavily  on  the  plate  will  be  recorded  as  a  spot  of  increased  density, 
common  examples  of  which  are  outlines  of  the  buttocks  of  a  thin 
individual  in  a  plate  of  the  entire  pelvis,  the  breasts  of  women  in 
anteroposterior  plates  of  the  chest  or  the  ears  in  lateral  skull  plates. 


Fig.  3. — Gas  gangrene. 

In  the  same  way  warts  and  fibromata  appear  as  rounded  areas  of 
increased  density,  which  when  they  occur  in  the  kidney  and  gall- 
bladder regions  may  strongly  suggest  calculi.  A  characteristic 
which  may  help  to  identify  them  is  that  they  ha^'e  extremely  sharp 
margins  because  of  the  fact  that  they  are  in  contact  with  the  plate. 
The  presence  of  fibromata  should  always  be  noted  in  the  patient's 
record. 


DEFECTIVE  PLATES  25 

Metallic  Salts. — Dense  shadows  of  the  metalHc  salts  may  be  seen 
where  there  are  bismuth  or  barium  residues  in  the  sinus  which  has 
been  injected  or  in  portions  of  the  gastro-intestinal  tract;  where 
zinc  or  mercurial  ointments  are  present  on  the  skin,  or  iodin  which 
in  any  form  casts  a  shadow  of  particular  density.  The  presence 
of  iodin  upon  the  skin  or  within  the  soft  tissues  as  a  result  of  intra- 
muscular injection  is  quite  striking  (Fig.  3).  Air  or  gas  in  the  soft 
tissues  also  gives  a  characteristic  picture. 

Gas  in  the  Intestinal  Tract. — Accumulations  of  gas,  particularly 
in  the  colon  where  it  overlies  the  spine,  the  wings  of  the  ilia  or 
sacrum,  arc;  sometimes  mistaken  for  areas  of  rarefaction  in  the  bone. 
Careful  inspection  will  reveal  the  presence  of  normal  bone  structure 
in  the  doubtful  area  or  the  patient  may  be  reexamined. 

Defective  Plates. — Plates  may  show  irregular  light  or  dark  areas 
as  a  result  of  defects  of  manufacture,  or  fogging  by  light  or  a;-rays. 
One  particularly  troublesome  defect  is  the  occurrence  of  localized 
thin  spots  in  the  emulsion  which  give  shadows  light  in  color  resem- 
bling those  of  stones.  Irregular  patterns  of  increased  or  diminished 
density  occasionally  result  from  uneA'en  immersion  of  the  plate  in 
the  developer;  these  are  very  sharply  marked  and  have  long  curved 
outlines.  Finger  marks  appear  on  plates  as  light  or  dark  spots, 
depending  upon  the  substance  present  on  the  finger  at  the  time  of 
impression;  their  presence  is  always  an  indication  of  faulty  dark- 
room technic. 

BIBLIOGRAPHY. 

Wells,  H.  Gideon:     Metastatic  calcification,  Arch.  Int.  Med.,  1915,  xv,  p.  574. 

Hetherington,  .1.  P.:  Causes  of  apparent  and  real  mistakes  in  ar-ray  diagnosis. 
Railway  Surg.  Jour.,  1915-16,  xxii,  p.  223. 

Pirie,  A.  H.:  Interpretation  of  a;-ray  negatives,  British  Med.  .Jour.,  1910,  part  2, 
p.  584. 

Jones,  R.,  and  Morgan,  D.:  On  osseous  foi-mations  in  muscles  due  to  injury,  Arch. 
Roent.  Ray,  1904-5,  ix,  p.  245,  and  190.5-6,  x,  pp.  10,  46,  72,  100,  199,  249,  275,  .304. 

Outerbridge,  G.  W.:  Non-teratomatous  bone  formation  in  the  human  ovary. 
Am.  .Jour.  Med.  Sc,  1916,  cli,  868. 

Klotz,  Oskar:  Obsolete  miliary  tubercles  of  the  spleen.  Am.  Jour.  Med.  Sc,  1917, 
clxxx,  p.  786. 


CHAPTER   II. 
ANATOMICAL  VARIATIONS  AND  DEVELOPMENT. 

Anatomical  variations  in  bone  structure  may  occur  anywhere 
in  the  skeleton  and  are  of  considerable  importance  aside  from  their 
interest  as  curiosities,  for  they  are  commonly  points  of  lowered 
resistance.  A  strain  or  injury  which  would  be  without  effect  on  a 
normally  constructed  individual  may  give  rise  to  severe  and  stub- 
born symptoms  when  such  anomalies  are  present.  This  is  particu- 
larly true  of  variations  in  the  spine. 

Skull. — The  skull  may  show  partial  absence  of  bones  or  variation 
in  the  width  of  sutures,  of  which  extreme  examples  are  acephalic 
monsters.  Thin  areas  appearing  as  holes  are  occasionally  seen  in 
the  frontal  and  parietal  regions  and  along  the  sagittal  suture. 
The  sinuses  and  mastoids  are  subject  to  wide  variation,  from  com- 
plete absence  to  enormous  size.  Cases  have  been  observed  in  which 
the  mastoids  communicated  with  the  sphenoid  sinus  anteriorly  and 
with  each  other  posteriorly. 

Vertebrae. — A  most  common  anomaly  in  the  spinal  column  is  the 
presence  of  extra  bodies,  e.  g.,  six  lumbar  or  thirteen  thoracic  seg- 
ments, or  of  extra  portions  of  bodies  which  take  the  form  of  a 
triangular  wedge  which  may  bear  an  extra  rib  when  it  occurs  in 
the  thoracic  region. 

Another  frequent  finding  is  the  failure  of  union  of  the  posterior 
ring.  All  degrees  of  this  condition  are  seen  from  bifid  spinous 
processes  to  complete  spina  bifida. 

There  may  be  increase  of  length  or  size  of  the  transverse  processes, 
particularly  in  the  last  cervical  and  last  lumbar  vertebrae.  There 
are  all  gradations  found  up  to  partial  or  complete  fusion  of  the  pro- 
cess with  the  sacrum,  or  so-called  sacralization.  These  enlarged 
processes  give  rise  to  symptoms  whenever,  on  account  of  size  or 
position,  they  cause  pressure  on  nerve  trunks  or  impinge  on  neigh- 
boring bones.  On  the  other  hand,  the  processes  of  the  first  lumbar 
are  often  short  and  have  accessory  ribs  attached;  these  may  be 
mistaken  for  fractures. 


VERTEBR.^ 


27 


Fig.  4. — Congenital  abnormality.     Wedge-shaped  vertebra. 


P;q_  5_ — Enlarged  sacralized  transverse  process  on  fifth  lumbar  vertebra. 


28  ANATOMICAL  VARIATIONS  AND  DEVELOPMENT 

While  spinous  processes  are  ordinarily  arranged  in  a  straight 
Hne,  slight  lateral  deviations  of  individual  processes  may  occur 
without  pathological  significance.  Unusually  long  or  thick  spinous 
processes  may  impinge  on  one  another,  especially  in  the  lumbar 
spine  in  cases  of  exaggerated  lumbar  curve. 

There  is  a  considerable  variation  in  the  plane  of  the  articular 
facets  at  the  lumbosacral  junction.  Normally  these  articular  sur- 
faces are  approximately  transverse,  but  one  or  both  may  be  rotated 
so  that  the  plane  of  the  articulation  between  them  is  anteroposterior. 
These  are  a  potential  source  of  symptoms  in  the  lower  back  because 
they  permit  of  various  degrees  of  forward  dislocation  of  the  fifth 
lumbar  vertebra  upon  the  sacrum. 


Fig.  6. — Double  cervical  ribs. 

Ribs. — One  anomaly  has  already  been  mentioned;  that  is,  the 
occurrence  of  extra  ribs  which  may  appear  in  the  lower  cervical  or 
upper  lumbar  regions  or  attached  to  extra  bodies.  These  cervical 
ribs  may  be  of  sufficient  length  to  articulate  with  the  sternum  or 
be  attached  to  the  first  rib.  They  are  usually  longer  than  they 
appear  on  the  plate,  due  to  foreshortening  of  their  shadow.    On  the 


VARIATIONS  OF  THE  TARSUS  29 

other  hand,  one  or  more  ribs  may  be  absent,  or  partially  so,  or 
adjacent  ribs  may  be  fused.  A  mild  form  of  this  latter  condition 
is  frequently  seen  near  the  sternal  end,  where  a  rib  may  flare  con- 
siderably before  its  attachment  to  the  costal  cartilage,  and  this 
enlargement  may  or  may  not  be  perforated. 

Scapulae. — These  bones  vary  considerably  in  thickness  and  holes 
may  occur  in  the  thin  regions,  especially  in  old  people;  in  the  same 
way  unusually  prominent  grooves  may  simulate  fractures.  There  is 
a  condition  known  as  congenital  elevation  of  the  scapula  (Sprengel's 
deformity) ,  in  which  a  partially  developed  scapula  is  found  high  up 
toward  the  neck.  In  cases  of  obstetrical  paralysis  there  may  be  an 
imperfect  development  of  the  lower  half  of  the  scapula. 


Fig.  7. — Congenital  abnormality  of  the  scapulge. 

Variations  of  the  Carpus. — Perhaps  the  most  important  anomaly 
here  is  the  divided  scaphoid,  which  is  to  be  differentiated  from  a 
fracture  of  the  scaphoid.  The  margins  of  the  halves  are  more 
rounded  and  smooth  and  the  space  separating  them  is  not  quite  so 
black  as  in  the  case  of  fracture.  The  semilunar  and  the  radial 
sesamoid  of  the  thumb  may  be  similarly  divided.  Small  extra 
bones  may  be  found,  of  which  the  most  common  is  the  styloid;  this 
develops  from  an  extra  center  of  ossification  lying  between  the 
trapezoid,  the  magnum  and  the  third  metacarpal. 

Variations  of  the  Tarsus. — The  astragalus  bears  a  backward  pro- 
longation of  variable  length  which  often  exists  as  a  separate  bone, 
the  trigonum;  when  present  it  must  be  differentiated  from  a  frac- 
ture of  a  long  process.  The  next  in  order  of  importance  is  the  tibiale 
externum,  a  small  detached  bone  which  sometimes  occurs  at  the 


30  ANATOMICAL  YARIATIOXS  AND  DEVELOPMENT 

posterior  end  of  the  scaphoid  on  the  inner  side  of  the  foot.  The 
peroneum  in  the  tendon  of  the  peroneiis  longus  overlying  the 
cuboid  may  be  subdivided. 

The  small  separate  center  of  ossification  on  the  outer  side  of  the 
posterior  end  of  the  fifth  metatarsal  may  persist  into  adult  life  as  a 
small  bone  called  the  vesalianum. 

Divided  sesamoids  in  the  tendons  of  the  flexor  hallucis  brevis 
beneath  the  head  of  the  first  metatarsal  are  fairly  common.  They 
must  be  carefully  dift'erentiated  from  fracture  of  single  sesamoids, 
which  are  extremely  rare. 

The  subject  of  variations  in  the  hands  and  feet  is  exhaustively 
treated  by  Dwight. 

Other  Bony  Variations. — In  e\'ery  roentgenological  practice  one 
may  encounter  cases  of  partial  or  complete  absence  of  long  bones, 
particularly  the  fibula,  radius  and  phalanges.  On  the  other  hand, 
supernumerary  bones,  usually  extra  fingers  or  toes,  may  also  be 
seen.  Fusion  of  bones  may  be  looked  for  occasionally;  this  is  most 
frequently  found  between  the  radius  and  the  ulna.  Adjacent  carpal 
and  tarsal  bones  may  be  united,  and  there  is  an  hereditary  anomaly 
in  which  the  first  and  second  phalanges  of  one  or  more  digits  may 
coalesce  with  obliteration  of  the  interphalangeal  joint.  Atavistic 
variations  may  occur,  as,  for  example,  the  hooked  supracondylar 
process  occasionally  found  on  the  inner  margin  of  the  humerus  above 
the  elbow. 

Ossification. — Variability  is  also  evident  in  the  time  of  appearance 
of  centers  of  ossification.  The  following  table  taken  from  Rotch 
and  Morris's  Anatomy  gives  figures  which  can  be  relied  upon  as 
a  working  average. 

Age  of  Age  of 

appearance.      fusion. 

Ribs:  Epiphyses  for  head  and  tubercle 15  2-3 

Clavicle:  Small  epiphysis  of  the  sternal  end 18  25 

Humerus:  Head 8  mos.      20 

Greater  tuberosity 3  20 

I^esser  tuberositj' 4  20 

(All  fuse  at  six  years  and  join  the  shaft  at  twenty  years). 

Capitellum 1  17 

Internal  epicondyle 5  18 

Trochlea 10  17 

External  epicondyle 12  17 

(The  capitellum,  ti'oclilea  and  external  epicondyle  join 
as  a  mass  at  seventeen  and  the  internal  epicondyle  at 
eighteen  j'ears.) 

Radms:  Head 5  17 

Lower  epiphysis 2  20 

Ulna:  Olecranon 10  17 

Lower  epiphysis 4  18 


OSSIFICATION  31 

Age  of  Age  of 

,^   ,~v^  appearance,      fusion. 

Carpus:   (IrTthe  order  of  appearance.) 

Magnum 1 

Uneiform       .   ■-\'^""V^ 1  to  1| 

Cuneiform     .      .."^y    $-■-  . 2  to  3 

Semilunar      .      ■.   '  \     ';       . 4  to  5 

Trapezium 5 

Scaphoid        .      .' 5  to  6 

Trapezoid      .       .'  • 6  to  8 

Pisiform  .      .      .      .' 12 

Metacarpals:  Epiphyses 3  20 

Phalanges:  Epiphyses 3  18 

Peh-is:  (Pubis  and  ischium  unite  at  eight  years;    the  acetabulum 
closes  at  sixteen  years.) 

Epiphyses  for 0  0 

Crest  of  ilium,  "I 

Ischial  tuberosity,  I  15  20 

Anterior  inferior  iliac  spine,  f 

Tubercle  of  pubes,  J 

Femur:  Head 1  19 

Greater  trochanter 4  18 

Lesser  trochanter 13  17 

Lower  epiphysis 8  mos.       20 

Patella:        .      .      .    ' 3  24 

Fibula:  Upper  epiphysis -.      .      .       .        4  24 

Lower  epiphysis 2  20 

Tibia:  Upper  epiphysis  9  mos.      22 

Lower  epiphysis  2  18 

Tarsus:   (In  order  of  appearance.)  ,.  ,_^^ 

Calcis        .      5^=^"V^f '^' .^ 6  mos. 

Epiphysis  of  calcis    .    ^ 10 

Astragalus      .      .      f—^'*'^ 7  mos. 

Cuboid 9  mos. 

External  cuneiform 1 

Internal  cuneiform 3 

Middle  cuneiform 3 

Scaphoid 4 

Metatarsals:  Epiphyses 3  to  8       20 

Phalanges:  Epiphyses 4  to  7       18 

Sesamoids  of  flexor  hallucis  brevis: 5 

Vertebrae:  Ossification  is  from  three  primary  centers,  one  for  the  body  and  one  for 
each  lateral  mass.  The  nucleus  for  the  Ijody  is  often  bilobed,  A\'ith  a  par- 
tial plane  of  cleavage  in  the  vertical  or  horizontal  diameter.  The 
laminse  unite  during  the  first  year.  Five  secondary  centers  described 
in  the  anatomies — namely,  thin  plates  on  the  upper  and  lower  surfaces 
of  the  body  and  the  tips  of  the  mammillary  tubercle,  transverse  and 
spinous  processes — appear  at  the  age  of  fifteen  to  twenty  years  and 
unite  at  twenty-five.  The  fifth  lumbar  vertebra  is  an  exception  in  that 
it  ossifies  from  five  centers,  one  for  the  body,  one  on  each  side  from 
which  is  developed  the  superior  articular  process,  pedicle  and  trans- 
verse process,  and  one  on  each  .side  which  subsequently  form  the 
inferior  articular  process,  lamina  and  spinous  process. 

It  is  well  to  bear  in  mind  that  epiphyses  which  appear  last  are 
the  first  to  unite  and  that  the  nutrient  foramen  is  directed  toward 
them;  that  ossification  begins  earliest  in  the  epiphyses  bearing  the 
largest  relative  proportion  to  the  shaft  (except  the  fibula);  that 
when  an  epiphysis  ossifies  from  several  centers,  they  fuse  together 
before  uniting  with  the  shaft. 


32  ANATOMICAL  VARIATIONS  AND  DEVELOPMENT 

Thomas  Morgan  Rotch  has  called  attention  to  the  fact  that  the 
time  of  appearance  of  the  carpal  centers  is  the  best  index  we  have 
of  the  actual  development  of  an  individual. 

Delayed  Union  or  Failure  of  Union. — Variations  in  the  normal 
process  of  the  union  of  epiphyses  are  of  great  importance  as  a  factor 
in  the  production  of  deformities.  For  example,  failure  of  develop- 
ment of  a  center  in  the  lateral  masses  of  the  fifth  lumbar  may  result 
in  scoliosis.  Abnormal  fusing  of  the  lower  epiphysis  of  the  radius 
produces  the  malformation  known  as  Madelung's  deformity,  in 
which  the  plane  of  the  radiocarpal  articulation  is  rotated  inward 
and  backward. 

Delayed  union  may  be  an  evidence  of  retarded  mental  or  physical 
development,  of  which  a  common  example  is  cretinism;  of  infections, 
prominent  among  which  is  lues;   or  of  injury. 

BIBLIOGRAPHy. 

Milne,  James  A.:  Congenital  absence  of  the  radii,  British  Med.  Jour.,  1915,  ii,  p. 
821. 

Piersol,  George  A.:  Congenital  perforations  of  the  parietal  bones,  Univ.  Peinia. 
Med.  Bull.,  1902,  xv,  p.  203. 

Skillei'n,  P.  G.:  Congenital  perforations  of  the  parietal  bones,  Ann.  Surg.,  1914, 
ix,  p.  807. 

Adams:  Relation  of  anomalies  of  lumbar  and  sacral  spine  to  lordosis.  Am.  Jour. 
Orthop.  Surg.,  1915,  xii,  p.  45. 

Hodgson,  F.  G. :  Congenital  deformities  of  the  vertebrae  and  I'ibs,  Am.  Jour.  Orthop. 
Surg.,  1916,  xiv,  p.  34. 

Case,  J.  T. :  Anacephaly  successfully  diagnosed  before  birth,  Surg.,  Gynec.  and  Obst., 
1917,  xxiv,  p.  312. 

Boorstein,  S.  W. :  Symmetrical  congenital  malformation  of  extremities,  Ann.  Surg., 
1916,  Ixiii,  p.  192. 

Rugh:     Sprengel's  deformity,  Tr.  Philadelphia  Acad.  Surg.,  1915,  xvii,  p.  62. 

Albers-Schonberg :  A  skeletal  anomaly,  the  supracondylar  process.  Am.  Jour.  Roent., 
1916,  iii,  p.  182. 

Geist,  E.  S.:  Supernumerary  bones  of  the  foot,  Am.  Jour.  Orthop.  Surg.,  1914-15, 
xii,  p.  403. 

Ruh,  H.  O.:    Acrocephalosyndactylism,  Am.  Jour.  Dis.  Children,  1916,  xi,  p.  281. 

Schueller,  A.:  Peculiar  cranial  defects  in  young  individuals.  Am.  Jour.  Roent.,  1916, 
iii,  p.  497. 

Ashhurst,  A.  P.  C:     Congenital  absence  of  the  fibula,  Ann.  Surg.,  1916. 

Peckham,  F.  E.:  Congenital  elevation  of  the  scapula,  British  Med.  Surg.  Jour., 
1916,  clxxiv,  p.  315. 

Dwight,  T. :  Closure  of  cranial  sutures  as  a  sign  of  age,  British  Med.  Surg.  Jour., 
1890,  cxxii,  p.  389. 

Hartung,  A.:  Congenital  anomalies  and  variations  of  the  bony  skeleton,  Am. 
Jour.  Roent.,  1916,  iii,  p.  430. 

Dunlop:     Adolescent  tibial  tubercle,  Am.  Jour.  Orthop.  Surg.,  1912-13,  ix,  p.  313. 

Goldwaite,'J.,  and  Painter,  C.  F. :  Congenital  elevation  of  shoulder,  Tr.  Am.  Orthop. 
Assn.,  xix,  p.  302. 

Barnes,  N.  P.:  The  sesamoids  of  the  flexor  brevis  hallucis.  New  Yoi'k  Med.  Jour., 
1915,  cu,  p.  940.     Tr.  Am.  Therap.  Soc,  1915,  p.  59. 

Clark,  D.  A.:  Sacralization  of  lumbar  vertebra,  Canadian  Med.  Assn.,  Jour.  1916, 
vi,  p.  914. 

Pryor,  J.  W. :  Ossifications  of  the  bones  of  the  hand,  Bull.  Univ.  Kentucky,  viii,  No. 
11,  November,  1916.     Reviewed  in  Am.  Jour.  Roent.,  1916,  iii,  p.  416. 

Sever,  J.  W.:    Obstetrical  paralysis,  Am.  Jour.  Orthop.  Surg.,  1916,  xvi,  p.  456. 


CHAPTER   III. 
FRACTURES  AND  DISLOCATIONS. 

FRACTURES. 

It  is  most  important  for  a  roentgenologist  to  have  a  thorough 
knowledge  of  roentgen  anatomy  and  of  the  surgical  pathology  of 
wound  and  fracture  repair.  Gross  fractures  are,  of  course^  obvious, 
but  in  a  doubtful  case  the  diagnosis  may  depend  entirely  upon  the 
breadth  of  his  anatomical  and  surgical  experience.  He  should  at 
least  know  that  the  more  accurately  a  fracture  is  reduced  the 
sooner  will  function  be  restored  and  the  smaller  the  callus  which 
results ;  that  calcification  begins  in  callus  in  from  two  to  four  weeks 
and  is  usually  complete  in  six;  that  at  first  callus  may  show  very 
little  evidence  of  lime  deposit  when  there  is  no  displacement  of 
fragments;  and  that  an  extensive  comminution  or  a  malposition 
of  fragments  should  be  accompanied  by  a  large,  thoroughly  calcified 
callus. 

The  prognosis  of  fractures  involving  joints  should  always  be 
guarded  because  of  the  fact  that  there  is  no  means  of  estimating 
from  the  roentgen  examination  how  much  damage  has  occurred  to 
the  soft  tissues  or  what  eiTect  their  repair  will  have  on  function. 
The  possibility  of  organization  and  calcification  in  extensive  hema- 
tomata  which  may  follow  injuries  to  the  supporting  structures 
should  always  be  remembered. 

The  question  of  union  is  often  a  difficult  matter  to  decide  from 
roentgen  evidence  alone.  One  cannot  determine  from  a  plate  show- 
ing a  fracture  without  evidence  of  bony  imion  whether  there  are 
soft  tissues  between  the  fragments  which  will  interfere  with  repair, 
whether  an  uncalcified  callus  is  present  or  whether  or  not  there  is 
firm  fibrous  union.  It  must  not  be  forgotten  that  non-union  is 
prone  to  occur  when  the  site  of  fracture  involves  a  nutrient  artery 
or  when  the  patient  is  syphilitic  or  asthenic. 

In  the  reduction  of  fractures  normal  weight-bearing  lines  should 
be  restored  as  far  as  possible  and  every  attempt  should  be  made  to 
replace  articular  surfaces  in  their  normal  planes  with  reference  to 
3 


34 


FRACTURES  AND  DISLOCATIONS 


the  shaft.     In  doubtful  cases  comparison  plates  of  a  symmetrical 
part  may  help  to  decide  whether  a  reduction  is  satisfactory. 

Fracture  lines  will  usually  become  obliterated  in  from  three  to 
six  months,  and  if  reposition  of  the  fragments  has  been  accurate  all 
evidence  of  the  injury  may  have  disappeared  in  that  time.  The 
shadow  of  linear  fractures  in  the  skull,  however,  may  persist  for  a 
longer  period,  but  ordinarily  are  not  visible  beyond  one  year  after 


Fig.  8. — Fracture  of  the  skull  in  a  child.    Compare  the  fracture  line  with  the  suture 

line  seen  above  it. 


the  injury.  In  any  fracture,  when  reduction  has  been  poor  or  the 
callus  formation  extensive,  evidence  of  the  deformity  may  persist 
for  life. 

The  roentgenogram  will  often  furnish  evidence  of  value  to  the 
surgeon  aside  from  the  position  of  the  fragments,  such  as  indica- 
tions of  a  pathological  process  in  the  bone  or  of  the  presence 
of  foreign  bodies  within  the  wound,  and  occasionally  the  early 
appearance  of  gas  in  the  soft  tissues  as  a  result  of  infection  with 
Welch's  bacillus. 


FRACTURES 


35 


Skull. — From  its  structure  the  skull  is  subject  to  linear  fractures 
which  appear  on  the  plate  as  thin  black  lines  with  sharp  ragged 
edges.  They  may  run  in  any  direction.  They  are  to  be  differen- 
tiated from  suture  lines,  diploic  vessels  and  arterial  grooves,  all  of 
which  have  fairly  definite  courses,  smooth  margins  and  are  lighter  in 
color.  Fracture  lines  may  open  up  sutures  or  follow  bloodvessel 
markings,  but  they  can  usually  be  traced  beyond  the  course  of  these 
normal  lines. 


Fig.  9. — Fracture  of  the  base  of  the  skull.      The  line  of  fracture  is  seen  in  the  petrous 
portion  of  the  temporal  bone. 


Comminuted  and  stellate  fractures  are  usually  obvious.  A 
depressed  fracture  often  appears  as  a  white  line  because  of  overlap- 
ping of  the  margins  of  the  break;  whenever  possible  profile  views 
of  them  should  be  obtained. 

Fractures  of  either  the  inner  or  the  outer  table  appear  as  areas 
of  slight  irregularity  in  the  density  and  structure  of  the  bone. 
Fractures  limited  to  the  base  are  frequently  overlooked;  a  vertical 
projection  of  the  base  in  addition  to  an  anteroposterior,  postero- 


36 


FRACTURES  AND  DISLOCATIONS 


anterior  and  both  lateral  views  should  be  a  routine  in  searching  for 
skull  fractures. 

Cranial  aerocele  may  develop  following  fracture  through  the 
sinuses,  especially  the  frontal  sinus.  They  are  produced  by  the 
increased  air  pressure  within  the  nasal  cavity  when  the  patient 
sneezes  or  blows  the  nose.  At  this  time  air  and  bacteria  may  be 
forced  through  the  _  fracture  into  the  cranial  cavity.  The  pocket 
containing  the  air  will  appear  on  the  plate  as  an  area  of  markedly 
diminished  density,  usually  in  the  frontal  region.  Plates  should  be 
taken  from  both  sides,  as  it  may  be  absent  in  one. 


Fig.  10. — Fracture  of  the  spine  (lateral  view). 


Vertebrae. — Fracture  lines  are  rarely  seen  in  the  bodies  of  verte- 
brae. "What  is  seen  is  abnormality  in  outline  or  in  relations  to 
neighborina;  vertebra?.    Crushing  fractures  of  the  bodies  occur  most 


FRACTURES 


37 


commonly  in  the  thoracic  and  lumbar  regions  as  the  result  of  severe 
injury.  They  may  be  overlooked  in  an  anteroposterior  view,  and  a 
lateral  view  should  always  be  obtained  as  a  check.  These  fractures 
run  a  long  clinical  course  and  give  no  evidence  of  callus  formation 
even  after  months  or  years.  Localized  hypertrophic  spurs  or 
bridges  to  adjoining  bodies  often  develop  after  these  injuries. 


Fig.  11. 


-Fracture  along  the  transverse  process  of  the  fifth  lumbar  and  of  the  fourth 
lumbar  on  the  right. 


Fractures  of  the  body  of  the  fifth  lumbar  may  occur  but  it  is  not 
common.  This  vertebra,  owing  to  its  tilted  position,  is  so  distorted 
in  the  average  picture  that  its  outlines  are  recognized  with  difRculty. 
A  diagnosis  of  fracture  of  this  body  should  not  be  made  without  a 
good  stereoscopic  inspection  of  its  direct  anteroposterior  diameter 
in  addition  to  a  lateral  view  if  possible. 

Transverse  processes  may  be  fractured  by  severe  lumbar  injuries, 
usually  several  vertebrte  being  affected.  There  may  or  may  not 
be  considerable  separation  of  the  fragments. 

Fracture  of  the  posterior  ring  and  transverse  processes  is  seldom 


38 


FRACTURES  AND  DISLOCATIONS 


directly  shown.  They  may  be  diagnosed  by  the  change  in  the  rela- 
tions of  the  vertebrEe  at  the  site  of  the  lesion,  usually  a  slight  rota- 
tion or  angulation  so  that  the  spinous  processes  of  the  vertebree 
above  the  lesion  are  out  of  line  with  those  of  the  one  below.  This 
condition  is  to  be  differentiated  from  the  slight  lateral  deviations 
which  frequently  occur  in  individual  spinous  processes  without 
significance. 


Fig.  12. — Tj-pical  Colles's  fracture.    The  lateral  view  shows  the  amount  of  deformity. 


Fractures  of  spinous  processes  may  be  suspected  from  deformities 
of  their  outlines  in  anteroposterior  views.  A  lateral  view,  however, 
will  usually  confirm  the  diagnosis. 

Pelvis. — Pelvic  fractures  are  usually  due  to  violent  injuries  such 
as  falls  and  crushes  and  the  resulting  deformity  is  easily  recognized. 
The  regions  about  the  sacro-iliac  and  the  symphysis  are  most  fre- 
quently involved.    A  typical  injury  consists  of  fracture  of  the  pubis 


FRACTURES  39 

with  more  or  less  wide  separation  of  the  sacro-ihac,  or  fracture 
through  the  sacrum  or  iUum  close  to  the  synchondrosis.  The  femoral 
head  may  be  driven  into  the  pelvis,  carrying  the  inner  wall  of  the 
acetabulum^before  it. 

Ribs. — Fractures  of  the  ribs  are  usually  obvious  but  may  be  over- 
looked in  the  overlapping  axillary  shadows.  Slight  rotation  of  the 
patient  will  bring  the  suspected  area  into  clear  view.  Fracture  of 
the  costal  cartilage  may  occur  which,  of  course,  is  not  evident  on  the 
roentgenogram  unless  the  cartilage  is  extensively  calcified. 


Fig.  1.3. — Colles's  fracture.     The  lateral  "s-iew  does  not  show  well  the  amount  of 
deformity  because  the  shadow  of  the  ulna  overlaps  that  of  the  radius. 


Carpus. — T^he  bones  involved  in  the  order  of  frequency  are  the 
scaphoid,  cuneiform  and  magnum.  These  fractures  are  often  asso- 
ciated with  those  of  the  radius  and  ulna  and  should  not  be  over- 
looked by  exclusive  attention  to  the  latter.  In  case  of  doubt  it  is 
advisable  to  secure  plates  of  both  wrists  in  symmetrical  position 
for  comparison. 

Colles's  Fracture. — ^This  is  probably  the  most  common  of  all  frac- 
tures. The  usual  deformity  is  a  compression  of  the  posterior  margin 
of  the  radius  which  results  in  a  backward  tilting  of  the  articular 


40 


FRACTURES  AND  DISLOCATIONS 


Fig.  14. — Shell  wound.     Shot  fired  from  German  submarine  off  Cape  Cod,  July  21, 
1918.     The  first  person  to  be  injured  on  American  territory. 


Fig.  15. — Fracture  of  the  anatomical  neck  of  the  humerus  along  the  epiphyseal  line. 
The  amount  of  deformity  is  not  well  shown  in  the  anteroposterior  ^new. 


FRACTURES  41 

surface  as  seen  in  the  lateral  position.  After  reduction,  the  former 
relation  of  the  styloid  processes  of  radius  and  ulna  should  be  restored 
and  the  plane  of  the  articular  surface  should  be  tilted  toward  the 
palmar  surface  forming  a  normal  angle  with  the  axis  of  the  shaft.  A 
special  type  of  this  injury  results  from  backfiring  of  automobiles  and 
consists  of  an  oblique  fracture  through  the  styloid  of  the  radius. 


Fig.  16. — Subperiosteal  fracture  of  the  tibiae.    The  line  of  fracture  is  not  visible,  Init 
there  is  a  definite  break  in  outline. 


Elbow. — Fractures  here  in  the  order  of  frequency  are  supra- 
condylar fractures  of  the  humerus,  fractures  of  olecranon,  head  of 
radius  and  coronoid  process.  The  two  latter  injuries  may  occur 
without  a  great  deal  of  displacement  and  may  be  overlooked  unless 
they  are  carefully  searched  for. 

Shoulder. — Fractures  of  the  anatomical  and  surgical  neck  are 
usually  the  result  of  falls  and  they  may  or  may  not  be  impacted. 
Stereoscopic  observation  of  this  region  or  a  lateral  view  is  always 
recommended  for  the  recognition  of  the  true  relation  of  the  frag- 
ments. 


42 


FRACTURES  AND  DISLOCATIONS 


Fractures  of  the  scapula  are  often  overlooked  on  flat  plates. 
Stereoscopic  examination  will  minimize  this  error. 

Tarsus. — ^Fractures  of  the  os  calcis  are  the  most  frequent.  They 
produce  more  or  less  disturbance  in  the  normal  structure  consequent 
upon  crushing  of  the  spongy  bone  and  deformity  of  outline.    The 


Fig.  17. — Fracture  into  the  knee-joint.    Also  fracture  of  the  patellae.     The  fracture 
is  not  visible  in  the  lateral  view. 


line  of  fracture  is  seldom  seen.  The  resulting  disability  is  usually 
severe.  More  rarely  fractures  of  the  astragalus  and  cuboid  may 
occur. 

Pott's  Fracture. — In  any  fracture  of  the  tibia  it  is  essential  that 
the  fibula  be  explored  throughout  its  extent  in  order  to  avoid  missing 
breaks  which  occur  at  a  different  level  from  that  of  the  tibial  injury. 
The  essentials  in  reduction  of  a  Pott's  fracture  are  that  the  weight- 


Fig.  18. — Old  fracture  of  the  femur,  with  extensive  callus  and  deformity. 


Fig.  19. — Pathological  fracture  of  the  upper  end  of  the  tibia  in  a  case  of  Paget's 

disease. 


Fig.  20.^-Greeii-stick  fracture  of  the  tibisB,  with  considerable  callous  formation 
suggesting  periosteal  changes. 


Fig.  21. — Fracture  of  the  neck  of  the  femur,  with  marked  absorption  of  the  neck. 


DISLOCATIONS  45 

bearing  line  be  restored  accurately  and  that  the  foot  be  slightly 
inverted. 

Knee. — Fractures  of  the  condyles  of  femur  and  tibia  have  the 
characteristics  of  fracture  involving  an}'  joint.  The  spine  of  the 
tibia  may  be  evulsed;  the  patella  may  sustain  a  transverse  break 
with  wide  separation  of  the  fragments  or  it  may  suffer  a  stellate 
fracture  or  shelving  fractures  of  the  upper  or  lower  margins  as  a 
result  of  division  of  the  attachment  of  the  patellar  tendon. 

Hip.- — These  fractures  occur  anywhere  in  the  neck  of  the  femur 
between  the  head  and  intertrochanteric  line.  ^^  hen  there  is  any  dis- 
placement of  the  fragments,  there  will  be  a  disturbance  of  Shenton's 
line,  which  is  a  smooth,  regular  curve  formed  by  the  upper  margin 
of  the  obturator  foramen,  the  inferior  border  of  the  neck  of  the 
femur  and  the  inner  margin  of  the  shaft. 

In  the  prognosis  of  hip  fractures  the  possibility  of  failure  of  union 
and  of  absorption  of  the  head  of  the  femur  must  always  be  kept  in 
mind. 


Fig.  22. — Double  congenital  dislocation  of  the  hip. 

DISLOCATIONS. 

Dislocations  of  the  spine  are  usually  accompanied  by  fracture. 
They  are  most  common  in  the  cervical  region.  The  first  cervical 
vertebra  may  be  displaced  backward  on  the  second  with  fracture 
of  the  odontoid  or,  more  rarely,  rotated  upon  the  second  without 
fracture  of  the  odontoid.  The  most  frequent  injury  is  a  forward 
displacement  of  the  upper  cervical  vertebrae  upon  the  ones  below 
in  the  region  of  the  third  to  the  seventh. 


46 


FRACTURES  AND  DISLOCATIONS 


\u,.  --■;.-    ni.«location  of  the  shoulder. 


Fig.  24. — Displacement  of  the  epiphysis  of  the  humerus- 


DISLOCATIONS  47 

The  sacro-iliac  joint  may  be  disarticulated  as  a  result  of  severe 
trauma.    The  so-called  sacro-iliac  slip  is  not  demonstrated  on  plates. 

Subeoracoid  dislocations  of  the  shoulder  usually  have  an  asso- 
ciated fracture  of  the  greater  tuberosity,  which  is  reduced  when  the 
head  of  the  humerus  is  replaced. 


Fig.  25. — Dislocation  of  the  sixth  on  the  seventh  cervical  vertebrse. 

In  the  carpus  the  semilunar  is  occasionally  dislocated  forward 
and  may  be  overlooked  in  an  anteroposterior  view  although  it  is 
obvious  in  a  lateral  one. 

Epiphyseal  separations  usually  involve  a  fragment  of  the  adjom- 
ing  shaft.  When  unaccompanied  by  a  fracture  of  the  shaft  they 
can  only  be  diagnosed  by  the  abnormal  relations  of  the  epiphyses, 


46 


FRACTURES  AND  DISLOCATIONS 


Fig.  23. — Dislocation  of  the  shoulder. 


Fig.  24. — Displacement  of  the  epiphysis  of  the  humerus. 


DISLOCATIONS  47 

The  sacro-iliac  joint  may  be  disarticulated,  as  a  result  of  severe 
trauma.    The  so-called  sacro-iliac  slip  is  not  demonstrated  on  plates. 

Subcoracoid  dislocations  of  the  shoulder  usually  have  an  asso- 
ciated fracture  of  the  greater  tuberosity,  which  is  reduced  when  the 
head  of  the  humerus  is  replaced. 


Fig.  25. — Dislocation  of  the  sixth  on  the  seventh  cer\-ical  vertebrse. 

In  the  carpus  the  semilunar  is  occasionally  dislocated  forward 
and  may  be  overlooked  in  an  anteroposterior  ^'iew  although  it  is 
obvious  in  a  lateral  one. 

Epiphyseal  separations  usually  involve  a  fragment  of  the  adjoin- 
ing shaft.  AVhen  unaccompanied  b}'  a  fracture  of  the  shaft  they 
can  only  be  diagnosed  by  the  abnormal  relations  of  the  epiph}'ses, 


48 


FRACTURES  AND  DISLOCATIONS 


which  do  not  often  occur.  Plates  of  symmetrical  parts  should  always 
be  taken  to  check  up  these  findings.  ^Yhen  these  separations  are 
promptly  and  accurately  replaced  there  is  rarely  any  interference 
with  the  growth  of  the  bone. 


Fig.  26. — Fracture  of  the  fifth  cervical  vertebree. 


Delayed  union  of  the  ossification  center  of  the  tibial  tubercle  is 
fairly  common,  particularly  in  the  presence  of  a  chronic  infection 
such  as  lues.  Separation  of  the  tibial  tubercle  (Osgood-Schlatter 
disease)  occurs  usually  as  a  result  of  indirect  violence.  The  tubercle 
is  elevated  from  the  diaphysis  and  the  margins  of  the  epiphyseal 
line  beneath  it  are  thickened  and  ragged.  A  similar  injury  may 
occur  to  the  epiphysis  of  the  os  calcis. 

Congenital  dislocations  of  the  hip  may  be  single  or  double.  They 
are  characterized  by  displacement  of  the  head  of  the  femur  upward 
on  the  ilium,  flattening  and  deformity  of  the  head,  and  shallowness 
of  the  acetabulum. 


BIBLIOGRAPHY  49 

Dislocations  may  occur  at  any  joint.  They  are  usually  obvious 
and  require  no  particular  description.  In  any  dislocation  careful 
search  should  be  made  after  reduction,  as  well  as  before,  for  fractures 
which  may  have  been  overlooked. 

BIBLIOGRAPHY. 

Cotton,  F.  J.:  Fractures  of  the  transverse  processes  of  the  vertebrae,  Interstate 
Med.  Jour.,  Supplement  on  Roentgenology,  October,  1916,  p.  1.38. 

Sever,  J.  W. :  Fracture  of  a  lumbar  vertebra,  Surg.,  Gynec.  and  Obst.,  1916, 
xxii,  p.  338. 

Young,  J.  K. :  Ununited  fractures  of  lumbar  vertebrae,  Ann.  Surg.,  1916,  Ixiii, 
p.  374. 

Boardman,  W.  W.:  Pseudofracture  of  the  sesamoid  bones  of  the  big  toe,  Surg., 
Gj'nec.  and  Obst.,  1915,  xxi,  p.  394. 

Crook,  J.  L. :    Fractures  of  the  astragalus.  Rail.  Surg.  Jour.,  1916,  p.  17. 

Cotton,  F.  J.:     Os  calcis  fracture,  Ann.  Surg.,  Ixiv,  p.  480. 

Codman,  E.  A.,  and  Chase,  H.  M.:  Fracture  of  the  carpal  scaphoid  and  disloca- 
tion of  the  semilunar  bone,  Ann.  Surg.,  May,  1905. 

Solomon,  E.  P.:  Unusual  surgical  conditions  following  trauma,  luternat.  Jour. 
Surg.,   1916,  xxix,  p.  248. 

Skillern,  P.  G. :  Fractures  of  sesamoid  bones  of  the  thumb,  Ann.  Surg.,  1915,  Ixii, 
p.  297. 

Scudder,  C.  L. :  Treatment  of  fractures,  with  notes  upon  a  few  common  disloca- 
tions, Ed.  8,  rev.  Philadelphia,  1915. 

Pancoast,  Henry  K. :  Roentgen  examination  of  the  spine;  surgery  of  the  spine 
and  spinal  cord,  Franzier-Appleton,  New  York. 


CHAPTER   IV. 
BONE  PATHOLOGY. 

Normal  bones  are  smooth  and  regular  in  outline,  the  cortex  is 
homogeneous  and  the  cancellous  tissue  of  imiform  consistency.  The 
thickness  of  the  cortex  and  the  texture  of  the  spongy  bone  vary 
considerably  with  the  individual.  The  cortex  is  thickest  along  the 
center  of  the  shaft  of  the  long  bone,  diminishing  toward  the  ends 
to  a  thin  line  which  continues  beneath  the  articular  cartilage.  The 
student  should  have  a  general  idea  of  the  normal  thickness  of  the 
cortex  of  each  individual  bone. 

Bone  disease  is  manifested  by  changes  in  size,  in  outlme  and  in 
density.  Various  forms  and  combinations  of  these  changes  result 
from  the  action  of  pathological  agents,  so  that  it  is  often  difficult 
from  the  roentgen  findings  alone  to  identify  positively  the  causati^■e 
factor.  For  this  reason  the  clinical  history  should  always  be  com- 
bined with  the  roentgen  findings  in  making  a  diagnosis. 

Bones  are  increased  in  size  in  osteomyelitis,  tumors,  Paget's 
disease,  s^-philis  and  cystic  disease.  They  are  diminished  in  size 
in  paralysis,  chronic  disease  of  neighboring  joints  or  in  develop- 
mental anomalies.  Changes  in  outline  result  from  periostitis,  which 
may  be  traumatic  or  infectious,  from  callus  formation  and  from 
tumors  of  the  bone. 

Changes  in  density  may  be  either  local  or  diffuse.  Diminished 
density  (increased  radiability)  occurs  as  a  result  of  disuse,  infection 
or  of  actual  destruction  from  involvement  by  tumor,  cyst  or  surgical 
intervention.  The  form  of  rarefaction  due  to  disuse  is  commonly 
referred  to  as  bone  atrophy  although  this  term  is  not  strictly  correct. 
There  are  two  t^'pes:  spotted  and  diffuse.  In  the  spotted  form  small 
local  areas  of  rarefaction  appear  scattered  through  the  spongy  bone 
and  may  be  noticed  as  early  as  one  week  after  complete  fixation 
of  the  parts.  This  condition  may  be  mistaken  for  metastatic  malig- 
nancy but  the  history  will  usually  differentiate  them.  The  diffuse 
form  occurs  in  more  chronic  processes  as  a  result  of  prolonged  fixa- 
tion, chronic  infections  in  neighboring  joints  or  atrophy  of  the  soft 
parts,  or  as  a  result  of  senile  changes.    As  the  name  implies,  it  is  a 


OSTEOMYELITIS 


51 


more  extensive  process  and  consists  in  a  uniform  decrease  in  density 
with  thinning  of  the  cortex  and  trabeculye.  Increased  density  occurs 
as  a  diffuse  process  in  old  osteomyehtis,  in  syphilis  and  in  Paget's 
disease.  It  is  found  locally  about  certain  low-grade  infections  and 
carcinomatous  metastases  of  slow  development. 

In  the  presence  of  a  pathological  process  in  bone,  the  following 
points  should  be  determined:  (1)  Is  there  involvement  of  the  med- 
ulla;   (2)  is  there  evidence  of  involvement  of  the  cortex;    (3)  is  there 


Fig.  27 


-The  bone  atropliy  of  disuse. 


any  associated  pathology  in  the  soft  parts;  (4)  is  the  lesion  multiple; 
(5)  is  it  confined  to  the  shaft  or  does  it  invade  the  epiphysis  and 
joint;  ((3)  are  neighboring  bones  affected;  (7)  is  it  destructive  or 
proliferative  or  both? 

Osteomyelitis. — The  characteristics  of  this  process  are  a  ^'ariable 
amount  of  destruction  of  medulla  and  cortex;  extensive  reaction 
of  the  periosteum  whenever  involved;  sequestration  and  irregular 
sclerosis.  It  may  attack  any  bone  at  any  age  and  rarely  extends 
beyond  the  epiphyseal  line. 


54 


BONE  PATHOLOGY 


Fig.  30. — Necrosis  of  the  skull. 


Fig.  31. — Osteomyelitis  of  the  ilium  in  a  child. 


TUBERCULOSIS 


55 


atrophy  may  be  severe  so  that  the  bones  appear  of  the  density  of 
soft  parts  with  finely  penciled  outlines.  Enlargement  and  squaring 
of  the  epiphyses  is  the  rule.  As  the  process  continues  there  is  more 
or  less  destruction  of  the  joint  surfaces  eventually  resulting  in  anky- 
losis as  the  process  heals.  Periostitis  may  develop  in  the  neighbor- 
hood of  tuberculous  lesions,  but  only  as  a  result  of  secondary 
infection. 


Fig.  .32. — Tuberculous  spine  (anteroposterior  view). 


The  rare  cases  of  tuberculosis  of  the  shaft  appear  as  an  irregular 
destruction  in  the  medulla  resembling  that  seen  in  a  syphilitic  osteo- 
myelitis but  without  involvement  of  cortex  or  periosteum. 

In  the  spine  tuberculosis  usually  begins  in  the  neighborhood  of 
the  intervertebral  disks  and  destroys  the  adjacent  body  or  bodies, 
which  collapse,  producing  a  k^'phos.     This  portion  of  the  spine  is 


56  BONE  PATHOLOGY 

often  suiToiinded  by  the  fusiform  shadow  of  a  prevertebral  abscess. 
Calcification  may  occur  later  in  such  an  abscess. 

Caries  sicca  is  a  slow  destructive  process  which  is  most  common 
in  the  shoulders.    It  causes  irregular  erosion  of  the  joint  surfaces  and 


Fig.  33. — Tiiherculous  spine  (lateral  view 


the  epiphyseal  end  of  the  humerus.  There  is  no  bone  atrophy;  on 
the  contrary,  there  may  be  slight  increase  in  density  in  the  affected 
area. 

Dactylitis  (spina  ventosa)  is  characterized  by  considerable 
increase  in  the  diameter  of  the  diseased  phalanx,  which  shows 
extensive  areas  of  destruction  in  the  medulla.    The  cortex  may  be 


SYPHILIS  57 

somewhat  thin  or  sHghtly  mcreased  in  thickness.  This  condition 
is  differentiated  from  syphiHtic  dactyUtis  by  the  fact  that  the 
enlargement  in  the  latter  is  due  to  periosteal  proliferation  with  the 
formation  of  a  collar  of  new  bone  outside  of  the  old  cortex;  there  is 
\QT\  little  involvement  of  the  medulla  and  from  giant-celled 
sarcoma  bv  the  absence  of  trabeculation. 


Fig.  34. — C'rauial  tub 


Syphilis.  —  Syphilis  is  a  destructive  and  proliferative  process, 
assuming  ^•aried  form.s  which  may  simulate  other  conditions.  It 
attacks  any  bone  at  any  age.  Its  commonest  manifestations  are 
periostitis  and  irregular  areas  of  destruction. 

Periostitis  is  usually  limited  to  the  shaft,  and  the  picture  which 
results  from  it  varies  according  to  the  age  and  activity  of  the 
process.  ^Yhen  acute  the  appearance  is  that  of  multiple  distinct, 
thin  laminse  laid  do^^m  upon  the  old  cortex,  and  the  outline  of  the 
free  margin  is  usually  irregular.  As  the  condition  becomes  more 
chronic  these  laminae  become  thicker  and  more  compact,  so  that 


58  BONE  PATHOLOGY 

ultimately  the  area  involved  becomes  as  dense  as  the  normal  cortex. 
At  the  same  time  the  surface  loses  its  fringy  character  and  becomes 
smooth,  although  it  may  be  more  or  less  irregular.  This  increase  in 
thickness  of  the  cortex  will  often  give  an  appearance  of  bowing,  as  is 
seen  in  the  so-called  sabered  tibia,  for  example.  It  should  be  noted 
that  this  thickening  of  the  cortex  usually  occurs  on  the  convex 
side  of  the  curve  as  compared  with  rickets,  where  it  appears  on  the 


Fig.  35. — Congenital  syphilis  (periosteal  type). 

concave  side.    There  is  often  an  accompanying  endosteal  prolifera- 
tion with  narrowing  of  the  medullary  canal. 

Periostitis  may  also  occur  as  small  local  elevations  of  the  perios- 
teum (bone  blisters)  at  times  near  the  ends  of  the  long  bones 
and  assumes  the  form  of  multiple  confluent  small  blisters.  There  is 
another  type  of  lesion,  a  sort  of  lacework  pattern,  which  consists  of 
strands  of  calcified  material  which  run  out  at  right  angles  to  the 
cortex  and  arch  together  at  their  terminations.    Running  through 


SYPHILIS 


59 


this  pattern,  parallel  to  the  shaft  and  midway  between  the  cortex 
and  the  periphery,  there  is  a  definite  thin  sheet  of  calcification. 
At  the  margins  of  the  process  where  it  blends  into  the  normal  bone 
is  the  usual  type  of  laminated  periosteal  thickening.  In  the  con- 
genital form  in  infants  the  periosteum  may  be  floated  away  from  the 
shaft  for  a  considerable  distance,  giving  a  clear  space  between  it 
and  the  cortex. 


ii_i 


Fig.  36. — Types  of  specific  periostitis  of  the  tibia;. 


Irregular  areas  of  destruction  may  occur  in  any  bone,  usually  as 
a  result  of  gummatous  changes.  In  the  skull  the  picture  is  striking 
and  represents  punched-out  areas  involving  borh  the  outer  and  inner 
table.  In  the  long  bones  they  are  usually  associated  with  periosteal 
changes,  although  at  times  a  bone  may  be  riddled  with  these  areas  of 
rarefaction  and  show  only  slight  periosteal  change.  This  is  partic- 
ularlv  common  in  the  more  acute  cases.    In  children  a  common  picture 


60 


BONE  PATHOLOGY 


is  the  so-called  jiixta-epiphyseal  lesion,  which  occurs  in  the  diaphysis 
near  the  epiphyseal  line.  They  are  characterized  at  first  by  an 
irregular  loss  of  substance  close  to  the  epiphyseal  line  and  perhaps 
a  slight  periostitis.    The  affected  area  later  becomes  sclerosed,  lead- 


FiG.  37. — Specific  periostitis  (congenital  type). 

ing  to  the  formation  of  a  white  line,  which  resembles  somewha.t 
that  seen  in  scorbutus. 

Joint  lesions  may  be  unilateral  or  symmetrical.    Ordinarily  little 
is  seen  beyond  an  increase  in  density  in  the  soft  parts,  due  to 


TYPHOID 


61 


effusion  and  synovial  thickening.  Later  on,  low  rounded  hyper- 
trophic growths  may  appear  about  the  margins  of  these  joints. 
Extensive  destructi\e  processes  may  sometimes  occur  in  the  epiphy- 
seal ends  of  bones,  causing  considerable  deformit}'.  Localized  areas 
of  destruction  suggesting  tuberculosis  may  sometimes  be  found  in 
the  epiphyses  of  children. 


Fig.  38. — Specific  dactilitis. 


In  the  spine,  lues  causes  the  destruction  of  one  or  more  bodies, 
usually  preserving  the  intervertebral  disks.  The  affected  area  is 
often  surrounded  by  calcified  masses  of  detritus.  Extensive  hyper- 
trophic changes  are  seen  on  the  neighboring  vertebrae. 

Typhoid. — Typhoid  in  the  bone  is  a  localized  destructive  and  pro- 
liferative process  of  long  duration,  usually  occurring  in  early  adult 
life.  It  is  characterized  by  circumscribed  areas  of  destruction  in  the 
ribs,  the  margins  of  vertebral  bodies  and  occasionally  the  cortex  and 
long  bones.  It  may  cause  a  local  periostitis  and  at  times  extensive 
irregular  periostitis  indistinguishable  from  that  of  syphilis.  In  the 
spine  the  first  roentgen  evidence  usually  appears  at  an  interval  of 
weeks  or  months  after  the  onset  of  symptoms,  when  a  small  area  of 
destruction  may  appear  in  the  corner  of  a  vertebra  close  to  the  disk. 


62  BOXE  PATHOLOGY 

Subsequently  coarse  hypertrophic  bridges  may  appear  about  this 
area  or  the  intervertebral  disk  ma}'  be  destroyed  with  a  resulting 
fusion  with  the  adjacent  vertebrae. 

Actinomycosis. — Actinomycosis  causes  a  chronic  osteomyelitis. 
It  usually  occurs  in  the  jaw,  and  is  characterized  by  its  slow  course 
and  by  the  pronounced  proliferation  of  bone  vrith  the  resulting 
general  increase  in  density. 

Oidiomycosis. — Oidiomycosis  may  attack  the  bone  in  severe  cases. 
The  roentgenogram  will  show  extreme  bone  atrophy  in  in^'olved 
areas,  with  more  or  less  irregular  destruction  which  suggests  tuber- 
culosis when  it  occurs  in  the  region  of  a  joint.  Local  areas  of  destruc- 
tion may  occur  in  the  cortex  with  loose  fuzzy  strands  of  proliferating 
periosteum  overlying  them. 

Leprosy. — Leprosy  is  characterized  in  its  early  stages  by  bone 
atrophy  of  the  terminal  phalanges  and  a  variable  amount  of  peri- 
ostitis. As  the  disease  progresses  these  phalanges  disappear  and 
there  is  progressiA'e  involvement  of  the  other  phalanges. 

Phosphorous  Poisoning. — Phosphorous  poisoning  causes  a  chronic 
osteomyelitis  of  the  jaw,  indistinguishable  roentgenologically  from 
the  ordinar}'  pyogenic  form. 

BONE  TUMORS. 

Li  the  study  of  hone  neoplasms  it  is  particularly  important  to 
determine  whether  or  not  they  are  chiefly  medullary  or  cortical  and 
as  far  as  possible  whether  or  not  there  is  involvement  of  the  soft 
tissues.  The  most  important  question  which  one  is  called  upon  to 
decide  is  whether  the  lesion  is  benign  or  malignant.  This  may  be 
a  matter  of  considerable  difficulty. 

Benign  Lesions. — Osteomata. — Osteomata  are  merely  irregular 
extensions  of  normal  bone  into  the  surrounding  tissues.  They  are 
characterized  by  their  very  slow  development,  by  the  fact  that  their 
structure  is  that  of  normal  bone  and  that  they  blend  into  the  bone 
at  their  site  of  origin.  They  are  most  commonly  found  near  the  ends 
of  the  long  bones  in  adults.  They  may  consist  of  hook-shaped  pro- 
cesses called  exostoses  or  broad,  romided  masses — true  osteomata. 

Enchondromata. — Enchondromata  cause  irregular  eccentric  enlarge- 
ments of  the  bones.  They  are  usually  multiple  and  are  most  common 
in  the  hands,  feet  and  long  bones.  There  is  considerable  distortion 
in  the  outline  as  a  result  of  tumor  growth  with  or  without  thinning 
of  the  cortex,  and  the  trabeculse  of  the  medulla  may  be  replaced  by 


BONE  TUMORS 


63 


a  homogeneous,  putty-like  shadow  or  by  multiple  small  rounded 
areas  of  rarefaction.  In  extensive  tumors  the  thinning  of  the  cortex 
may  be  so  extreme  that  it  is  reduced  to  small,  thin  flakes  of  bone  on 
the  periphery  of  the  growth,  which  in  the  flat  plate  are  projected 
upon  the  tumor  and  must  be  differentiated  from  calcification  within 
the  growth. 


Fig.  39. — Osteomata  of  the  femur. 


Multiple  Cartilaginous  Exostoses. — Multiple  cartilaginous  exostoses 
are  an  hereditary  anomaly  of  development,  in  which  large  cartilagi- 
nous outgrowths  of  diminished  density  and  irregular  outline  appear 
in  the  region  of  the  epiphyseal  lines.  These  growths  are  multiple, 
usually  involving  most  of  the  epiphysis,  and  cause  considerable 
deformity  and  interference  with  the  normal  development  of  the  bone 
involvement. 


64 


BONE  PATHOLOGY 


Bone  Cysts. — Bone  cysts  occur  in  the  long  bones  and  in  the  jaw. 
They  are  characterized  by  sharply  defined,  rounded  or  oval  areas 
of  rarefaction  containing  few  or  no  trabeculse.  The  process  is 
entirely  within  the  shaft,  and  spreads  longitudinally  in  the  medulla 
without  involving  the  cortex  which,  however,  may  be  considerably 
thinned  from  pressure.    There  is  no  deformity  in  outline  unless  a 


Fig.  40. — Multiple  cartilaginous  exostosis. 


fracture  has  occurred.  Spontaneous  fractures  are  often  the  first 
indication  of  the  presence  of  a  lesion  and  they  are  usually  followed 
by  extensive  callous  formation. 

Osteitis  Fibrosa. — Allied  to  cystic  disease  is  a  rare  condition  which 
may  involve  one  or  all  of  the  bones.  It  consists  in  the  replacement 
of  the  normal  structure  by  irregular  strands  of  trabeculse  enclosing 


BONE  TUMORS 


65 


multiple  cysts  which  vary  in  size  and  shape.  There  is  considerable 
expansion  in  the  bone,  and  spontaneous  fractures  are  common  as 
a  result  of  the  thinning  of  the  cortex.  There  is  no  periosteal  pro- 
liferation. When  cysts  occur  in  the  neighborhood  of  epiphyseal 
lines  there  may  be  interference  with  growth. 


Fig.  41. — Bone  cyst  in  upper  end  of  humerus.  Fig.  42. — Bone  cyst  and  fracture. 

Osteitis  Deformans  (Paget's  Disease). — Osteitis  deformans  is  a 
slowly  progressive  process  which  usually  involves  most  of  the 
bones,  but  in  rare  forms  may  be  limited  to  one,  particularly 
one  end  of  the  tibia.  It  shows  extensive  thickening  of  the  cortex 
on  both  sides,  with  enlargement  and  bowing  of  the  bone  and  re- 
arrangement of  the  trabeculse  into  strands  or  bundles  running  lon- 
gitudinally. The  medulla  shows  mottled  areas  of  rarefaction  which 
usually  extend  into  the  epiphysis.  This  involvement  of  the  epiphysis 
is  important  in  the  differentiation  from  lues,  which  very  rarely 
affects  the  epiphysis  in  the  same  manner.  In  the  skull  this  condition 
causes  an  increase  in  the  size  of  the  head  as  a  result  of  expansion 
of  the  cranial  bones,  which  show  great  thickening  of  both  tables 
and  coarse  mottling  throughout  the  diploe. 
5 


66 


BONE  PATHOLOGY 


Malignant  Lesions. — Sarcoma. — Giant-celled  sarcoma  is  probably 
not  a  true  malignancy  and  should  be  classed  with  the  benign  lesions, 
although  one  case  in  our  experience  became  malignant  following 


Fig.  43. — Paget's  disease. 


intensive  roentgenization.  This  tumor,  which  is  of  slow  growth, 
occurs  as  an  isolated  lesion,  usually  near  the  end  of  a  long  bone  or 
in  the  jaw.  The  growth  is  eccentric,  that  is,  it  causes  asymmetrical 
enlargement  of  the  bone  and  tends  to  balloon  out  the  cortex  rather 


BONE  TUMORS 


67 


than  to  spread  along  the  medullary  canal.  Ordinarily  it  does  not 
break  through  the  cortex.  The  mass  of  the  tumor  consists  of 
irregular  areas  of  rarefaction  containing  coarse  trabeculae,  sometimes 
suggesting  a  mass  of  soap-bubbles, 

Osteosarcomata  are  slowly  growing  masses  which  usually  originate 
in  the  medulla  of  long  bones  or  in  the  flat  bones.  Their  charac- 
teristic is  an  early,  extensi^'e,  irregular  deposition  of  lime  salts 
throughout  the  growth.  They  are  not  particularly  malignant. 
They  may  be  mistaken  for  an  old  osteomyelitis  but  the  history  will 
usually  differentiate  them. 


Fig.  44. — Giant-cell  sarcoma  of  the  finger. 


Bound  or  S'pindle-celled  (niedvllary)  sanomaia  are  of  very  rapid 
development  and  metastasize  early.  They  involve  the  shaft,  often 
the  greater  part  of  it.  Their  appearance  is  that  of  extensive  rare- 
faction with  destruction  of  trabeculse,  early  invasion  of  the  overly- 
ing cortex  and  extension  into  the  soft  parts.  Often  there  is  a  com- 
plete loss  of  bone  substance  in  the  area  occupied  by  the  tumor,  the 
outline  of  which  can  be  traced  into  the  soft  tissue.    At  times  the 


68  BONE  PATHOLOGY 

picture  resembles  that  of  a  virulent  osteomyelitis  which  should  be 
differentiated  by  the  history  and  clinical  course. 

Periosteal  sarcomata  are  rapidly  growing  tumors  which  are 
extremely  malignant  and  which  originate  from  the  periosteum, 
most  commonly  along  the  shaft  of  the  long  bones.  In  the  earliest 
stages  they  may  appear  as  a  slight  erosion  of  the  cortex  or  a  blister 


Fig.  45. — Medullary  sarcoma  of  the  lower  end  of  the  fibxila. 

beneath  the  periosteum  which  is  elevated  by  the  growth.  As  the 
growth  increases,  the  shadow  of  its  outline  in  the  soft  tissues  becomes 
evident,  A  most  characteristic  finding  is  the  presence  of  fine  strands 
of  calcified  material  radiating  into  the  substance  of  the  tumor  and 
terminating  freely.  There  may  be  slight  erosion  of  the  cortex  which 
ends  abruptly  at  the  limits  of  the  growth.    In  the  early  stages  careful 


BONE  TUMORS 


69 


examination  of  the  entire  periphery  of  the  bone  may  be  necessary 
to  demonstrate  the  lesion. 

Carcinoma. — Carcinoma  is  practically  always  metastatic  and  may 
involve  any  one  or  all  of  the  bones.  It  may  be  identified  by  a 
moth-eaten  appearance  due  to  the  irregular  destruction  of  bone 


Fig.  46. — Periosteal  sarcoma  of  the  femur  in  a  child. 


substance  and  its  replacement  by  tumor  mass.  The  cortex  may  be 
involved,  but  ordinarily  only  in  the  later  stages.  There  is  no  perios- 
teal reaction  and  no  change  in  outline  unless  spontaneous  fracture 
occurs.  In  the  skull  it  appears  as  irregular  areas  of  bone  destruction 
which  typically  are  limited  to  the  diploe  and  do  not  involve  either 
table.    When  the  spine  is  involved  there  is  more  or  less  extensive 


70  BONE  PATHOLOGY 

destruction  of  several  bodies  but  ordinarily  the>'  do  not  collapse 
owing  to  the  fact  that  the  dense  tumor  tissue  affords  considerable 
support.  This  is  of  importance  in  the  differentiation  from  tubercu- 
losis and  lues,  in  which  collapse  of  the  affected  bodies  is  the  rule. 

There  is  a  second  form  of  metastatic  carcinoma  usually  secondary 
to  a  tumor  of  the  prostate  or  breast,  which  is  of  extremely  slow 
development— cases  having  been  seen  ten  years  after  the  recognition 


Fig.  47. — Metastatic  carcinoma  of  the  femur. 

of  the  primary  disease.  It  is  characterized  by  the  extensive  produc- 
tion of  new  bone  in  the  vicinity  of  the  growths.  Its  usual  site  is  in 
the  spine  and  pelvic  bones,  which  become  greatly  increased  in  density 
and  coarsely  mottled  from  the  intermingled  areas  of  rarefaction  and 
condensation.  The  bones  are  sometimes  enlarged  and  may  be 
mistaken  for  osteitis  deformans.  The  long  history  may  also  be 
suggestive  of  this  condition.     More  careful  inspection  will  show 


BONE  TUMORS 


71 


that  the  picture  is  produced  by  adjacent  areas  of  bone  destruction 
and  proliferation,  with  the  latter  predominating,  and  that  there  is 
no  evidence  of  the  rearrangement  of  trabeculae  into  bundles,  which 
is  typical  of  Paget's  disease.  Furthermore,  the  distribution  of  the 
lesions  is  quite  dissimilar.  Osteitis  deformans  more  commonly 
attacks  the  long  bones  and  skull  and  rarely  involves  the  spine,  while 
this  form  of  carcinoma  shows  a  preference  for  spongy  bone.  The 
demonstration  of  a  primary  growth  particularly  in  the  prostate 
should  be  conclusive. 


Fig.  48. — Metastatic  sarcoma  of  the  skull  in  a  child. 


Rarer  Bone  Tumors. — Any  type  of  tumor  may  be  encountered 
in  the  bones  and  the  roentgen  appearance  of  different  pathological 
entities  is  naturally  very  similar,  as  they  are  manifested  only  by 
irregular  areas  of  bone  destruction  which  are  not  characteristic  of 
any  particular  neoplasm.  They  are  commonly  diagnosed  as  carci- 
noma roentgenologically.  Under  this  heading  come  h}T)ernephroma, 
myeloma,  m;yTioma,  fibroma,  etc.  The  age  of  the  patient  and 
the  distribution  of  lesions  may  help. 


72 


BQNE^  PATHOLOGY 


Hypernephroma. — Hypernephroma  occurs  as  multiple  small  areas 
of  rarefaction  with  loss  of  trabecule  and  no  attempt  at  new  bone 
formation.  It  may  be  distributed  throughout  the  skeleton  and  is 
particularly  common  throughout  the  skull,  sternum,  ribs  and  bodies 
of  vertebrae. 


Fig.  49. — Multiple  medullary- 
mj'eloma. 


Fig.  50. — Pulmonary  osteoarthropathy. 


Myeloma.— Myeloma  is  a  low-grade  malignancy  of  slow  evolu- 
tion which  typically  causes  small  multiple  areas  of  rarefaction, 


BONE  TUMORS 


73 


usually  limited  to  the  flat  bones,  although  extensive  single  lesions 
have  been  obseived  in  long  bones.  Owing  to  its  slow  growth,  defor- 
mities in  outline  occur  as  a  result  of  thinning  and  expansion  of  the 
cortex  overlying  the  growth.  For  the  same  reason  spontaneous 
fracture  is  fairly  common.  Its  appearance  often  resembles  that  of 
carcinoma,  although  the  areas  are  usually  smaller,  more  rounded 
and  more  sharply  defined.  It  is  accompanied  by  the  presence  of 
Bence-Jones  bodies  in  the  urine.  Some  cases  have  responded  well 
to  roentgen  therapy. 


Fig.  51. — Acromegalia. 


Myxoma. — M^'xoma  is  a  slowly  growing  tumor  which  usually 
involves  a  single  long  bone.  It  causes  irregular  enlargement  of  the 
whole  shaft,  irregular  rarefaction  of  the  medulla  and  thinning  of 
the  cortex.  It  may  also  invade  the  soft  tissues  and  show  small 
spicules  of  periosteal  bone  in  the  soft  tissue  mass,  suggesting  sar- 
coma. Pathological  examination  may  be  necessary  in  a  dift'erential 
diagnosis. 


74 


BONE  PATHOLOGY 


DISEASES  OF  NUTRITION. 

Pulmonary  Osteoarthropathy.— The  first  stage  in  this  process  is 
enlargement  of  the  soft  tissues  of  the  ends  of  the  fingers,  so-called 


Fig.  52. — Bowing  of  the  tibia  in  the  adult,  due  to  racliitis. 


club  fingers.  Later  proliferation  of  the  periostemn,  which  is  difficult 
to  distinguish  from  that  of  lues,  appears  along  the  metacarpals  and 
phalanges  and  frequently  about  all  the  long  bones.     As  a  result, 


DISEASES  OF  NUTRITION 


75 


these  bones  have  a  thickened  cortex  and  in  the  later  stages  are 
increased  in  width. 

Acromegaly. — Acromegaly,  in  addition  to  the  characteristic  changes 
in  the  skull,  gives  rise  to  a  general  enlargement  of  the  skeleton. 
A  typical  finding  is  the  change  which  occurs  in  the  cancellous  bone, 
the  texture  of  which  becomes  very  coarse  and  heavy.  There  is  also 
clubbing  of  terminal  phalanges. 


Active  rachitis. 


Rickets. — This  is  a  disease  usually  occurrmg  during  the  first 
dentition.  It  shows  in  the  roentgenogram  a  flaring  and  widening 
of  the  diaphysis  above  the  epiphyseal  line ;  the  bone  between  shaft 
and  epiphysis  is  increased  in  thickness,  with  ragged,  fringy  margins. 
The  shaft  side  of  the  epiphyseal  line  may  appear  as  a  broad  white 


76 


BONE  PATHOLOGY 


line,  as  a  result  of  the  deposit  of  lime  salt.  The  shaft  may  be  bowed 
and  the  cortex  considerably  thickened  on  the  concave  side  of  the 
curve.  Mild  periosteal  proliferation  sometimes  occurs.  There  may 
be  areas  of  decreased  density  in  the  cranial  bones  along  with  promi- 
nence of  the  frontal  and  parietal  bosses.  In  the  form  which  comes 
on  later  during  adolescence  there  is  irregular  rarefaction  and  enlarge- 
ment of  the  long  bones,  resulting  in  disturbance  of  the  weight-bearing 
lines,  as,  for  example,  coxa  vara  and  genu  varum. 


Fig.  54. 


-Scurvy,  well  advanced.     Case  showing  separation  of  the  periosteum  and 
displacement  of  the  epiphysis  due  to  hemorrhage. 


Scorbutus. — This  condition  is  commonly  seen  during  the  first 
years  of  life  and  may  or  may  not  have  an  associated  rickets.  The 
earliest  evidence  of  its  presence  is  a  wiiite  line  in  the  shaft  margin 
of  the  epiphyseal  zone.  This  line  is  thinner,  more  dense  and  more 
sharply  defined  than  the  one  seen  in  rickets.  Later  in  the  clinical 
course  subperiosteal  hemorrhages  appear  as  more  or  less  extensive 
irregular  elevations  of  the  periosteum  over  the  entire  length  of  the 


DISEASES  OF  NUTRITION 


77 


shafts  of  the  long  bones.  In  severe  cases  the  hemorrhage  may  be 
sufficient  to  produce  separation  of  the  epiphysis.  The  final  process 
consists  of  organization  of  the  clot  which  produces  a  shadow  of 
considerable  density  about  the  shaft. 


Fig.  55. — Osteogenesis  imperfecta. 


Differential  diagnosis  is  from  lues  and  osteomyelitis.  Lues  is 
more  apt  to  be  a  generalized  process,  the  periosteum  is  less  elevated 
and  epiphyseal  dislocation  does  not  appear.  In  osteomyelitis  there 
is  destruction  of  the  shaft  which  is  unaffected  in  scorbutus,  and  the 
clinical  picture  is,  of  course,  quite  characteristic. 


78 


BOXE  PATHOLOGY 


Achondroplasia  (Chondrodystrophy  Fetalis)  .—The  bones  in  this 
condition  are  shortened,  compact  and  at  times  bowed.  The  epiphy- 
seal Hne  is  very  thin  and  sharply  defined  and  closes  considerably 
earlier  than  the  normal.  This  results  in  an  adult  whose  long  bones 
are  very  much  shortened,  with  corresponding  loss  of  weight.  This 
process  is  said  to  involve  only  those  bones  in  which  ossification  has 
begun  before  the  sixth  month. 


Fig.  56. — Osteomalacia  in  a  child. 


Osteogenesis  Imperfecta  (Fragilitas  Ossium,  Periosteal  Dysplasia 
or  Osteopsathyrosis). — In  the  infantile  form  of  this  disease  the  bones 
show  great  diminution  in  lime  salts  and  thinning  of  the  cortex 
without  changes  in  size.  This  results  in  a  weakening  of  the  structure 
of  the  bones  and  multiple  spontaneous  fractures  occur,  usually 
followed  bv  a  fair  amount  of  callous  formation. 


DISEASES  OF  NUTRITION 


79 


In  the  adult  form  the  bones  are  nearly  normal  in  size  and  calcium 
content  but  usually  present  considerable  deformity  as  a  result  of 
the  multiple  spontaneous  fractures  which  the  patient  has  suffered. 


Fig.  57. — Osteomalacia,  with  pathological  fracture  in  adult  female. 


Osteomalacia. — This  is  a  condition  of  extreme  and  irregular 
diminution  in  the  density  of  all  the  bones.  There  is  usualh'  consider- 
able deformity  due  to  bending  and  spontaneous  fractures  with  poor 
-callous  formation.  This  condition  may  result  from  any  one  of  several 
causes  and  is  therefore  not  properly  to  be  regarded  as  an  entity. 


80 


BONE  PATHOLOGY 


A  TABULATION  OF  THE  FINDINGS  IN  THE   MORE  COMMON  BONE 
LESIONS  FOR  USE  IN  DIFFERENTIAL  DIAGNOSIS. 


Osteomyelitis. 

1.  Usually  a  single  lesion. 

2.  Both  destructive  and  proliferative. 

3.  A  disease  of  the  shaft,  involving  the 

epiphysis — rarely  the  joint. 

4.  Produces  bone  atrophy. 


Usually  starts  in  the  medullary  por- 
tion and  involves  the  cortex,  peri- 
osteum, and  soft  tissue. 

Occurs  at  any  age. 

Enlargement  and  deformity  of  the 
bone. 


Syphilis. 


1.  Usually  a  multiple  process. 

2.  Usually  proliferative.     The  gumma- 

tous form,  which  is  rare,  is  both 
proliferative  and  destructive. 

3.  Usually  a  disease  of  the  shaft,   but 

rarely   it    involves    the    joint    and 
epiphysis. 

4.  Usually  confined  to  the  periosteum, 

but  may  involve  the  cortex.    Does 
not  caupe  bone  atrophy. 

5.  May  appear  at  any  age. 


6.  There  maj'  be  enlargement  and  con- 
siderable deformity  of  the  bones. 

Periosteal  Sarcoma. 

1.  Always  single. 

2.  Proliferative. 

3.  Involves  the  shaft  only,  as  a  rule — 

rarely  invades  the  epiphysis.  Never 
enters  a  joint. 

4.  Invades  the  soft  tissues  in  the  im- 

mediate neighborhood,  presenting 
characteristic  ray-like  formation. 
Bone  atrophy  is  absent. 

5.  Common  in  young  adults. 

Cakcinom.\. 

1.  Multiple  lesion. 

2.  Usually    purely    destructive;    rarely 

there  is  bone  proliferation  about 
the  invaded  area. 

3.  Attacks  the  medulla  and  cortex  of  the 

long  and  flat  bones.  The  perios- 
teum and  joints  are  not  involved. 

4.  A  disease  of  adults. 

5.  In  the  proliferative  type,  the  bones 

may  be  enlarged  and  deformed. 


Tuberculosis. 

1.  Usually  a  single  lesion. 

2.  A  destructive  process. 

3.  A  disease  of  the  joints  and  epiphyses. 

4.  Rarely   invades   the   shaft   and   soft 

tissues ;  the  neighboring  bones  show 
marked  atrophy.  The  periosteum 
is  not  involved. 

5.  More  common  in  children. 


Paget's  Disease. 

1.  A  multiple  lesion. 

2.  Proliferative. 


3.  Involves  the   shaft   and   epiphysis- 

the  joints  are  not  affected. 

4.  Late  adult  life. 


5 .  Overgrowth  of  the  bony  structures 
and  abnormal  trabeculation.  The 
soft  tissues  are  not  invaded. 


Giant-cell  Sarcoma. 

1.  Single  lesion. 

2.  Destructive  type. 

3.  Involves  the  medullary  portion  of  the 

shaft;  the  cortex  may  be  thin  but 
is  not  invaded.  The  joints  and  soft 
tissues  are  unaffected. 

4.  Childhood  and  young  adults. 


5.   The  bone  is  not  deformed. 

Bone  Cyst. 

1.  Single  lesion. 

2.  Purely  destructive. 


3.  Located  in  the  medullary  portion  of 

shaft.    Does  not  invade  the  cortex, 
joint,  or  soft  tissue. 

4.  Children  and  young  adults. 

5.  The  bone  is  not  deformed. 


BIBLIOGRAPHY  81 


Medullary  Sarcoma.  Osteoma 

1.  Siagle  lesion.  1.  Usually  a  single  lesion. 

2.  Purely  destructive  in  the  bone.  2.  Purely  proliferative. 

3.  Involves  the  shaft ,  rarely  the  epiphy-         3.  Arises  from  the  cortex.  Never  invades 

sis;    never  the  joint.  the  bone. 

4.  The  cortex  of  the  bone  is  destroyed         4.   Common    in     children     and     young 

and  the  soft  tissues  invaded.  adults. 

.5.  Usually  in  young  adults.  5.  There    may    be    some    deformity    of 

bone  from  pressure.     Structure  of 
the  growth  resembles  normal  bone. 


BIBLIOGRAPHY. 

Kuth,  J.  R. :    Early  congenital  bone  lues,  Arch.  Ped.,  1915,  xxxii,  p.  244. 

Risley,  E.  H.:    Skeletal  cancer,  British  Med.  Surg.  Jour.,  1915,  clxxii,  p.  584. 

Boorstein,  S.  W. :  Syphilis  of  bones  and  joints,  Surg.,  Gynec.  and  Obst.,  1914, 
xviii,  p.  46. 

Fitz  Simmons,  H.  .1.:  Multiple  bone  tuberculosis,  British  Med.  Surg.  Jour.,  1914, 
clxx,  p.  547. 

Locke,  E.  A.:  Secondary  hypertrophic  osteoarthropathy,  Arch.  Int.  Med.,  1915, 
XV,  p.  659. 

Kessel,  L.:  Relation  of  hypertrophic  osteoarthropathy  to  pulmonary  tuberculosis, 
Ai-ch.  Int.  Med.,  1917,  xix,  p.  239. 

Cotton  and  McCleary:    Myxoma  of  femur,  Am.  Jour.  Roent.,  1918,  v,  p.  95. 

Fassett,  F.  J.:    Kohler's  disease,  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  p.  1155. 

Hetzel:    Kohler's  disease,  Am.  Joar.  Orthop.  Surg.,  1917,  xv,  p.  214. 

Lock,  N.  F.:  Note  on  tunnels  and  large  cavities  in  bone,  British  Jour.  Surg.,  July, 
1916,  p.  145. 

Murphy,  J.  B.:  Bone  and  joint  diseases  in  relation  to  typhoid  fever,  Surg.,  Gynec. 
and  Obst.,  1916,  -xxiii,  p.  119. 

Wile,  Udo.  J.,  and  Senear,  F.  E.:  A  study  of  the  involvement  of  the  bones  and 
joints  in  early  syphilis,  Am.  Jour.  Med.  Sc,  1916,  clii,  p.  689. 

Wilde:    Acute  bone  atrophy  after  an  accident,  Am.  Jour.  Roent.,  1916,  cxi,  p.  54. 

Perussia,  F. :  Phosphorus  necrosis  of  the  maxillge,  Am.  Jou".  Roent.,  1916,  cxi,  p. 
177. 

Gouldesbrough,  C:  Pulmonary  osteoarthropathy,  Arch.  Roent.  Ray,  1913,  xviii, 
p.  208. 

Ehrenfried,  Albert:  Multiple  cartilaginous  exostoses,  Jour.  Am.  Med.  Assn.,  1915, 
Ixiv,  p.  1642. 

Murphy,  John  B.:    Typhoid  spine,  Surg.,  Gynec.  and  Obst.,  1916,  xxiii,  p.  119. 

Gaenslen,  F.  J.:    Osteitis  deformans,  Am.  Jour.  Orthop.  Surg.,  1915,  xiii,  p.  96. 

Bythell,  W.  S.  J.:  Bone  tumors:  in  proceedings  of  Roj^al  Society  of  Medicine, 
Electrotherapeutical  Section,  March  20,  1914,  Arch.  Roent.  Ray,  1914,  xix,  p.  185. 

Royce,  C.  E.:    Sarcoma  of  the  scapula,  Surg.,  Gynec.  and  Obst.,  1916,  xxiii,  p.  74. 

Weber:    Multiple  cartilaginous  exostoses,  Am.  Jour.  Roent.,  1916. 

Hirsch:    Bone  tumors,  Am.  Jour.  Electro,  and  Radiol.,  January,  1917. 

Boggs,  R.  H.:   X-ray  in  bone  disease,  New  York  Med.  Jour.,  1917,  cv,  p.  112. 

Symmers,  D.,  and  Vance,  M.:  Hemangio-endothelioma,  Am.  Jour.  Med.  Sc, 
1916,  clxxix,  p.  28. 

ConneU;    Giant-celled  tumor  of  bone,  Surg.,  Gynec.  and  Obst.,  1915,  xxii,  p.  427. 

Barrie,  G.:    Cancelloiis  bone  lesions,  Ann.  Surg.,  1915,  Ixi,  p.   129. 

Coon,  C.  A.:    Bone  and  joint  .syphilis,  Am.  Jour.  Surg.,  1915,  xxix,  p.  211. 

Mclntyre,  Milne:  Diffuse  myxochondroma  of  a  long  bone.  Lancet,  December, 
1916,  p.  1013. 

Cotton,  F.  J.:  Diagnosis  of  periosteal  sarcoma  with  the  x-ray,  British  Med.  Surg. 
Jour.,  1916,  p.  946. 

Rugh,  J.  T.:  Typhoid  spine,  with  autopsy  findings,  Am.  Jour.  Orthop.  Surg.,  1915, 
xiii,  p.  289. 

Henderson,  M.  S.:  Osteochondromatosis,  Am.  Jour.  Orthop.  Surg.,  1917,  xv,  p. 351. 
6 


82  BONE  PATHOLOGY 

Kohler,  A.:   Kohler's  disease,  Aliinchen.  med.  Wchnschr.,  1908,  Iv,  p.  1923. 

PfaUer:   Kohler's  disease,  Surg.,  Gynec.  and  Obst.,  1913,  xvii,  p.  625. 

Neve,  A.:  A  case  of  leprosy  diagnosed  by  x-rays,  British  Med.  Jour.,  December  4, 
1915,  p.  814. 

Connell,  F.  G.:  Giant-celled  tumor  of  bone,  Tr.  Western  Surg.  Assn.,  1915,  xxiv, 
p.  221. 

Denit,  G.  B.:   Giant-celled  sarcoma  of  pehis,  Ann.  Surg.,  1915,  Ixii,  p.  636. 

Landon,  L.  H.:  Ostitis  fibrosa  cystica,  Tr.  Philadelphia  Acad.  Surg.,  1915,  xvii, 
p.  90. 

Van  Zwaluwenburg:    Ostitis  fibrosa.  Jour.  Michigan  Med.  Soc,  1915,  xiv,  p.  46. 

For  complete  bibliography  of  ostitis  fibrosa  cystica  and  of  bone  cysts,  see  Blood- 
good:  Ann.  Surg.,  Iri,  Nr).  2,  p.  145.  Muller:  Univ.  Pennsylvania  Med.  Btill.,  Septem- 
ber, 1906,  p.  173.  Stiiunpf:  Deutsch.  Ztschr.  f.  Chir.,  1912,  pp.  114,  417.  Silver: 
Am.  Jour.  Orthop.  Surg.,  1911-12,  ix,  563. 

Vance:    Multiple  mj^eloma,  Am.  Jour.  Med.  Sc,  November,  1916,  p.  691. 

HaussHng,  F.  R.,  and  Martland,  H.  S.:  Bone  tumors,  Ann.  Surg.,  1916,  Ixiii,  p.  454. 

McCrae,  T.:  Tjiphoid  and  paratj-phoid  spondylitis,  with  bony  changes  in  the 
vertebra?,  Am.  Jour.  Med.  Sc,  1906,  clix,  p.  878. 

Lord,  F.  T.:  Analysis  of  twenty-six  cases  of  typhoid  spine,  Boston  Med.  Surg. 
.Jour.,    1902,    cxl^d,   p.   689. 

Koch,  J.  C.:    Laws  of  bone  architecture.  Am.  Jour.  Anat.,  1917,  xxi,  p.  177. 

Walker,  C.  A.,  and  Cummins,  W.  T.:  Echinococcic  bone  disease.  Jour.  Am.  Med. 
Assn.,  1917,  Ix^dii,  p.  839. 

Fisher,  A.  L.:  Sj^philitic  bone  and  joint  lesions  sim\ilating  tuberculosis.  Jour. 
Am.  Med.  Assn.,   1917,  Ixviii,  p.  366. 

Grey  and  Carr:    Bone  atrophy,  Johns  Hopkins  Med.  Bull.,  1915,  xxvi,  p.  381. 

Elaine,  E.:  Idiopathic  infantile  osteopsathj-rosis.  Am.  Jour.  Roent.,  1916,  iii, 
p.  438. 

Hiu-ndtz,  S.  H.:  Monoosteitic  form  of  Paget's  disease.  Am.  Jour.  Roent.,  1915, 
ii,  p.  755. 

Langnecker,  Hany  L. :  Lesions  of  the  lumbosacroiliac  region.  Jour.  Am.  Med.  Assn., 
1915, Ixv,  p.  1866. 

Jacobsohn:    The  causes  of  rickets.  New  York  Med.  Jour.,  1916,  ciii,  p.  68. 

Hirsch,  1.  S.:  Bone  tumors.  Am.  Jour.  Electro,  and  Radiol.,  1917,  xxxv,  pp.  1,  72, 
113,  116. 

Bythell  and  Scott:  Bone  tumors,  Proc.  Roy.  Soc.  Med.,  London,  1913-14,  Electro- 
therapeutic  Section,  pp.  63-78. 

Lovett:   Rickets,  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  p.  2062. 

Crawford,  H.  de  L. :  Congenital  syphilis  of  hands  and  feet,  Tr.  Roy.  Acad.  Med., 
Ireland,  1915,  xxxiii,  p.  224. 

Berard  and  Alamartine:  Bone  disease  simulating  bone  tumors.  Rev.  de  Chir., 
1914-15,  p.  137. 

Cameron,  H.  C:  Osteogenesis  imperfecta,  Proc.  Roy.  Soc.  Med.,  1915-16,  Section 
on  Diseases  of  Children,  ix,  part  1,  p.  43. 

Hess,  J.  H.:    Osteogenesis  imperfecta.  Arch.  Int.  Med.,  1917,  xix,  p.  163. 

Ehrenfried,  A.:  Hereditary  deforming  chondroplasia,  "multiple  exostoses,"  British 
Med.   Surg.   Jour.,    1916,   clxxiv,   p.   327. 

Montgomery:    Congenital  exostoses,  Internat.  Chn.,  1916,  xxvi.  111,  p.  140. 

Carman,  R.  D.,  and  Fisher,  A.  C. :  Multiple  congenital  csteochondromata,  Ann. 
Surg.,   1915,  Ixi,  p.  142. 

MacCoUum,  W.  G.:  Chondrodystrophia  fetalis,  Johns  Hopkins  Hosp.  Bull., 
1915,  xxvi,  p.  182. 

Young,  J.  K. :    Chondrodystrophia  fetalis.  Arch.  Ped.,  1914,  xxxi,  p.  371. 

Honeij,  James  A.:  Bone  changes  in  leprosy.  Am.  Jour.  Roent.,  New  York,  October, 
1917. 


CHAPTER   V. 

SKULL. 

RoENTGEXOLOGY  of  the  skull,  its  contents,  sinuses,  mastoids  and 
teeth  has  become  a  field  of  its  own.  There  is  naturally  a  close  asso- 
ciation between  the  teeth  and  sinuses,  and  the  two  should  always  be 
studied  together.  The  bones  of  the  skull  are  subject  to  fractures 
and  diseases  affecting  the  skeleton  generally,  which  ha^"e  already 
been  considered. 


Fig. 


-Oxjcephalus 


The  suture  line  and  the  grooves  of  the  vessels  are 
obliterated. 


Hydrocephalus. — Hydrocephalus  is  perhaps  the  commonest  brain 
condition  with  which  the  roentgenologist  has  to  deal  in  children. 
The  picture  is  one  of  chronic  intracranial  pressure — enlargement  and 
great  thinning  of  the  vault  of  the  skull,  with  exaggeration  of  the 
convolutional  depressions  and  often  separation  of  the  sutures. 


84 


SKULL 


Oxycephalus. — A  condition  in  which  there  is  early  union  of  the 
cranial  sutures  followed  by  increased  intercranial  pressure.  On  the 
Roentgen  plate  the  skull  appears  small  and  thin  with  absence  of 
the  suture  line.  Areas  of  diminished  densit}'  due  to  pressure  of  the 
convolution  are  unusually  prominent. 


Fig.  59. — Tumor  of  the  brain  located  in  the  frontal  lobe.     The  plate  shows  localized 

pressure  atrophy. 


Brain  Tumor. — Brain  tumor  rareh'  gi^'es  direct  e-\'idence  of  its 
presence.  Localized  erosion  of  the  cah^arium  o^'er  the  lesion  or 
increased  density  due  to  new  bone  formation  by  the  dura  overh'ing 
it  or,  very  rarely,  calcification  in  the  mass  itself  ma^'  help  to  localize 
the  process.  In  90  per  cent,  of  the  cases  all  that  appears  on  the  plate 
is  the  evidence  of  intracranial  pressure  and  the  common  findings 
are  compression  or  destruction  of  the  posterior  clinoid  processes, 
enlargement  of  the  bloodvessel  channels  distributed  to  the  affected 


SELLA  85 

area  and,  at  times,  increased  impressions  of  the  cerebral  convolu- 
tions. In  severe  cases  separation  of  one  or  more  suture  lines  may 
be  present. 

Subdural  Hemorrhages. — Subdural  hemorrhages  cannot  be  diag- 
nosed on  the  roentgenogram.  Thin  areas  in  the  temporal  region  or 
areas  of  increased  density  in  the  parietals  are  often  erroneously 
pointed  out  as  hemorrhages. 


Fig.  60. — Pituitary  tumor.    The  sella  is  enlarged  and  its  floor  destroyed. 


Sella. — True  lateral  views,  preferably  stereoscopic,  are  essential 
for  the  proper  observation  of  Uie  sella.  It  is  subject  to  considerable 
variation  both  in  size  and  shape,  of  which  the  latter  is  the  more 
important.  As  already  noted,  deformity  of  the  posterior  clinoids 
may  occur  as  a  result  of  tumor  in  any  portion  of  the  brain.  Hypo- 
physeal tumors  cause  a  ballooning  of  the  sella  with  thinning  of  the 
floor  and  usually  of  both  anterior  and  posterior  clinoid  processes. 
Associated  with  these  changes  may  be  seen  more  or  less  enlargement 
of  the  sinuses,  elongation  of  the  mandible  and  general  enlargement 


86  SKULL 

of  the  bones,  particularly  those  of  the  hands  and  feet.  The  clinoids 
occasionally  meet,  bridging  in  the  roof  of  the  sella.  Attention  has 
been  called  to  the  fact  that  this  is  a  common  occurrence  in  epilepsy 
and  sterility.  (Faulty  technic  in  securing  views  of  the  sella  which 
are  not  true  laterals  may  cause  an  appearance  of  roofing  which  a 
true  lateral  will  correct.) 


Fig.  61. — Very  large  sinuses.     Anatomical  variations. 

Calcified  Pineal  Glands. — Calcified  pineal  glands  are  frequently 
seen  in  individuals  over  thirty.  They  appear  as  dense  white  spots 
a  millimeter  or  two  in  diameter  located  in  the  mesial  plane  several 
centimeters  above  the  mastoids.      They  are  without  significance. 

Sinuses. — For  a  proper  study  of  the  sinuses  anteroposterior, 
lateral,  and  vertical  projections  are  necessary.  The  anteroposterior 
plate,  in  addition  to  the  outline  of  the  sinuses  themselves,  affords 


SINUSES 


87 


some  evidence  of  the  shape  of  the  septum,  size  of  the  turbinates  and 
relative  depth  of  the  floor  of  the  nose  and  the  floor  of  the  antra. 
The  lateral  plate  is  particularly  useful  in  checking  up  the  antero- 
posterior of  the  frontals  to  determine  their  depth  and  the  thickness  of 
their  walls.  Teeth  or  foreign  bodies  in  the  antra  may  be  well 
projected  in  this  view  which  often  gives  a  clue  to  the  condition  of 
the  sphenoidal  sinus,  but  is  of  little  value  in  the  study  of  the  ethmoids. 
The  vertical  projection  outlines  the  sphenoidal  sinus  very  well. 
The  normal  sinus,  because  of  its  air  content  and  thin  walls, 
appears  as  a  more  or  less  darkened  area  with  sharply  defined  edges. 


Fig.  62. — Sinusitis.     All  of  the  sinuses  on  the  left  side  are  dull. 


Any  change  in  the  amount  of  air  contained  within  it  or  in  the  thick- 
ness of  its  walls  will  be  recorded  as  a  change  in  density  on  the  plate, 
and  both  these  factors  must  be  considered  in  making  a  diagnosis. 
This  is  particularly  true  in  the  case  of  the  frontals,  where  a  degree  of 
density  which  is  normal  for  one  individual  may  be  quite  pathological 
in  the  case  of  another  whose  air  space  is  larger  and  walls  thinner 
and  whose  sinuses  should  therefore  appear  darker.  For  the  recog- 
nition of  pathology,  it  is  essential  to  compare  the  two  sides  and  to 
have  a  fairly  definite  mental  picture  of  the  appearance  of  the  normal 
sinus.  In  the  study  of  the  frontals  both  anteroposterior  and  lateral 
views  must  be  combined. 


88  SKULL 

A  general  haziness  with  a  sHght  increase  in  density  in  one  or  more 
sinuses  usually  means  thickening  of  the  lining  membrane.  This  may 
be  corroborated  in  the  case  of  the  frontals  by  the  additional  evidence 
of  thickening  of  the  septal  markings  which  become  hazy  and  are 
surrounded  by  an  indefinite  zone  of  slightly  increased  density,  as 
contrasted  with  the  sharply  outlined  normal  septa.  This  general 
thickening  may  involve  only  one  sinus,  all  of  the  sinuses  on  one  side, 


Fig.  63. — Osteoma  of  the  frontal  sinus. 

or  those  of  both  sides.  In  the  last  condition,  some  difficulty  may  arise 
from  the  fact  that  comparison  of  opposite  sides  is  impossible  and  the 
roentgenologist  must  fall  back  upon  his  empirical  knowledge  of 
what  the  normal  should  be. 

Granulations,  pus  or  tumors  produce  a  shadow  of  greater  density, 
which  usually  obliterates  the  sinus  completely.  Their  shadows  are 
identical  in  every  respect,  so  that  it  is  usually  impossible  to  tell 


POLYPI  89 

^Yhich  one  we  are  dealing  with  from  the  roentgen  plate  alone.  When 
there  is  a  fluid  exudate  in  a  sinus  it  is  often  possible  to  make  out  a 
fluid  level  in  the  suspected  cavity  upon  a  plate  taken  with  the  patient 
upright.  However,  the  absence  of  a  fluid  level  does  not  rule  out  pus. 
Tumors  of  the  sinuses  will  ordinarily  give  some  evidence  of  their 
nature  by  erosion  or  invasion  of  the  walls  or  adjacent  bones,  ^'ery 
rarely  a  sinus  or  portion  of  the  orbit  will  be  occupied  by  a  dense 
osteoma.  Absence  of  frontal  sinuses  is  fairly  common  and  must  be 
differentiated  from  thickening  which  has  obscu'-ed  the  margins  and 
obliterated  the  outline  of  a  well-developed  sinus.  A  lateral  view 
will  show  no  evidence  of  a  sinus  and  no  room  for  it  at  the  base  of 
the  frontal.  Careful  inspection  of  the  anteroposterior  view  should 
show  the  presence  of  bone  structure  in  the  suspected  area. 


Fig.  64. — Sclerosed  and  normal  ma.stoid. 

It  must  not  be  forgotten  that  a  sinus  may  be  found  filled  with 
mucoid  material  at  operation  and  yet  cast  no  abnormal  shadow  on 
the  plate.  In  fact,  mucoceles  by  erosion  of  the  bone  overlying  them 
often  appear  as  areas  of  diminished  density. 

Polypi. — Polypi  can  sometimes  be  visualized  in  the  frontals  and 
antra  as  romided  areas  of  slightly  increased  density.  The  entire 
sinus  will  usually  appear  somewhat  hazy  as  a  result  of  the  thickened 
membrane. 

Burnham  has  called  attention  to  the  occurrence  of  a  dense 
fusiform  shadow  OA'erlapping  the  septum  in  a  case  of  gumma  of 
the  septum. 


90 


SKULL 


The  patency  and  course  of  nasal  ducts  may  be  determined  from 
roentgenograms  made  with  opaque  probes  in  situ. 

Mastoids. — Plates  of  both  sides  should  always  be  taken  as  a 
routine  for  purposes  of  comparison.  Normally  the  cells  are  bright 
and  clear  with  sharply  outlined  walls.  The  broad  grooves  of  the 
lateral  sinus  can  usually  be  traced  down  across  the  mastoid  as  a 
streak  of  diminished  density.  In  an  acute  mastoiditis  there  is 
general  haziness  of  the  affected  cells  and  blurring  of  their  margins, 
followed  later  by  destruction  of  the  cells  and  loss  of  their  outlines, 
which  are  replaced  by  an  indefinite  area  of  increased  density.  In 
chronic  cases  there  is  more  or  less  absence  of  cells  and  a  variable 
degree  of  sclerosis. 

Teeth. — The  roentgenologist  should  have  a  general  knowledge  of 
the  development,  anatomy  and  pathology  of  the  teeth,  for  he  will 
surely  be  called  upon  to  do  a  certain  amount  of  dental  roentgenology. 
An  understanding  of  the  course  of  dentition  is  helpful  not  only  in 
the  interpretation  of  dental  conditions  in  children  and  adults  but 
also  in  the  determination  of  the  ages  of  children.  The  following 
table  from  Thoma  can  be  relied  upon  as  a  working  basis. : 


Tooth, 
temporary. 

Central  incisor . 
Lateral  incisor. 

Cuspid 

First  molar.  .  .  . 
Second  molar.  . 
Central  incisor. 
Lateral  incisor. 

Cuspid 3  years 

First  bicuspid.  ...       4      " 
Second  bicuspid.  .       5      " 

First  molar Before  birth 

Second  molar ....      5  years 
Third  molar 9      " 


Calcification 
begins. 


1  year 
1     " 


Calcification 
complete. 

1 5  years 

2        " 
20  months 
20 

10  years 
10 
12 
12 
12 
9  to  16 

17  to  18 

18  to  20 


Eruption. 

6  to    8  months 
1  to    9 

17  to  18 
14  to  15 

18  to  24 

7  to    8  years 
7  to    8     " 

12 
10 
11 
6 
13 
18 


Shed. 
7  vears 

s"   " 

12       " 

10  " 

11  " 


The  importance  of  good  technic  in  dental  roentgenology  must  be 
insisted  upon.  This  includes  adequate  exposures  with  the  least 
possible  amount  of  distortion,  preferably  from  several  angles  and 
the  use  of  both  plates  and  films. 

Anomalies  of  development,  irregularity  of  eruption,  misplaced 
and  unerupted  teeth  are  perhaps  the  most  frequent  examples  and 
the  diagnosis  is  obvious.  Impaction,  which  is  particularly  common 
in  the  molars,  is  a  common  finding.  The  presence  of  retained 
temporary  teeth  is  readily  recognized. 

In  adult  teeth  the  roentgen  examination  is  often  of  value  in  demon- 


Alveolar  abscess 


91 


strating  fracture  of  the  teeth  below  the  gum  le^'el,  the  extent  of 
carious  processes,  and  in  determining  the  extent  and  position  of 
root  canal  fillings  and  the  results  of  operative  procedures.  Pulp 
stones  are  often  revealed  in  the  pulp  cavities.  They  are  small, 
round,  dense  masses  frequently  multiple,  which  form  in  the  pulp 
chamber  of  one  or  more  teeth.  They  have  been  accused  of  being 
the  cause  of  severe  neuralgias.  Inasmuch  as  they  are  frequently 
seen  without  s;y'TQptoms,  their  significance  is  questionable. 

The  most  important  pathological  conditions  with  which  the 
roentgenologist  has  to  deal  are,  of  course,  pyorrhea  and  alveolar 
abscess. 


Fig.   65. — Multiple  pus  pockets  involving  the  roots  of  the  molars  and   bicuspids. 


Pyorrhea. — Pyorrhea  in  its  early  stages  gives  little  roentgen 
evidence  aside  from  a  slight  increase  in  the  width  of  the  dark  line 
about  the  tooth,  which  represents  the  peridental  membrane.  As  the 
infection  continues  and  the  alveolar  process  becomes  involved,  the 
bone  retracts  from  the  neck  and  finally  the  roots  of  the  teeth,  which 
are  then  kept  in  place  only  by  the  fibrous  tissue  of  the  gums.  As 
a  general  rule,  when  the  retraction  of  the  alveolar  process  involves 
over  half  of  the  root  the  tooth  is  doomed. 

Alveolar  Abscess. — Alveolar  abscess  in  the  acute  stage,  like  osteo- 
myelitis, gives  no  roentgen  evidence  of  its  presence.  Very  shortly, 
however,  rarefaction  appears  about  the  root  involved  and  at  first 


92 


SKULL 


4                                                                              ^^H 

Fig.  66. — i,  pyorrhea  pocket  about  the  mesiobuccal  root  of  the  left  upper  first 
molar;  S,  advanced  Rigg's  disease,  with  absorption  and  recession  of  the  alveolus, 
but  without  definite  pyorrhea  pockets;  3,  chronic  abscesses  at  apices  of  palatal  and 
mesiobuccal  roots  of  the  left  upper  first  molar;  4.  osteomyelitis  arising  from  the  roots 
of  the  left  lower  first  molar;  5,  proliferative  inflammatory  granuloma,  with  central 
softening  at  the  apex  of  the  right  upper  second  bicuspid;  6,  devitalized  left  lower 
molar  showing  caries,  root  canal  fillings  and  small  apical  granuloma;  7,  impacted  right 
lower  third  molar,  with  pus  pocket;  8,  small  pyorrhea  pockets  about  both  upper 
central  incisors;    transverse  fracture  of  the  left  upper  incisor. 


CYSTS 


93 


the  resulting  dark  area  merges  into  the  structure  of  the  surrounding 
cancellous  bone.  As  the  process  becomes  more  chronic,  a  limiting 
wall  appears  about  it  and  the  picture  then  becomes  one  of  a  definite 
dark  sac  attached  usually  about  the  apex  of  the  root.  This  is  the 
familiar  form  of  alveolar  abscess.  Pathologically  most  of  them  are 
found  to  be  a  mass  of  granulation  tissue  containing  a  certain  number 
of  bacteria,  less  frequently  a  definite  abscess  cavity  with  a  lining 
membrane.  Erosion  of  the  tip  of  the  root  extending  into  this  cavity 
is  often  seen  and  in  long-standing  cases  deposits  of  new  bone  laid 
down  about  the  apex  of  the  root  produce  bulbous  enlargements  and 
may  wholly  or  in  part  fill  the  old  abscess  cavity.  The  treatment 
of  such  an  abscess  is  one  to  be  decided  by  all  the  other  evidence, 
medical  and  dental,  which  can  be  acquired.  Not  every  tooth  which 
shows  an  alveolar  abscess  should  be  extracted.    Each  case  should  be 


Fig.  67. — Impacted  upper  canine  tooth. 


treated  upon  its  indi^•idual  merits.  Abscesses  must  not  be  confused 
with  extensions  of  the  antra  downward  or  pockets  in  the  antra  in 
the  region  of  the  upper  bicuspids  and  molars  nor  with  the  sub- 
mental foramen  which  frequently  overlies  the  apex  of  a  lower 
bicuspid.  Films  of  the  upper  incisors  occasionally  show  the  shadow 
of  the  nostril  overlying  a  root  which  simulates  an  abscess. 

Cysts. — Cysts  are  fairly  common  in  the  jaw.  There  are  two  forms: 
root  cyst  and  dentigerous  cyst.  The  former  arises  perhaps  most 
frequently  from  an  old  alveolar  abscess.  It  appears  as  a  large 
rounded  area  of  rarefaction  in  the  jaw,  usually  attached  to  or 
partially  enclosing  one  or  more  tooth  roots  and  showing  little  or  no 
evidence  of  trabeculation.  They  may  be  multiple.  Dentigerous 
cysts  have  a  similar  appearance  except  that  they  develop  from  a 
buried  tooth  bud  and  generally  contain  teeth  or  portions  of  them. 
The  bony  structure  of  the  jaws  may  be  subject  to  any  of  the  diseases 


94 


SKULL 


which  affect  the  rest  of  the  skeleton.    Osteomyelitis  is  fairly  common 
and  shows  the  same  irregular  destruction  and  proliferation   seen 


Fig.  6S. — Simple  cyst  of  the  jaw 


Fig.  69. — Dentigerous  cyst. 


CYSTS 


95 


elsewhere.  A  particular  sort  of  osteomyelitis  occurs  with  phos- 
phorous poisoning;  the  bone  becomes  increased  in  density  and 
thickness  as  a  result  of  new  bone  production  which  is  followed  later 
by  suppuration  and  necrosis  represented  by  irregular  rarefaction. 
Syphilis  occurs  occasionally  in  the  form  of  an  irregular  mottling 
of  the  bone  due  to  extensive  spotted  rarefaction. 

Tumors  of  all  sorts  may  be  encountered — giant-cell  sarcoma  and  the 
more  malignant  forms  of  sarcoma,  carcinoma  and  hypernephroma, 
for  example.  Their  appearance  is  identical  with  that  of  similar 
growths  in  other  flat  bones.     In  addition,  the  jaw  is  the  seat  of  a 


Fig.  70. — Cystoma  of  the  jaw. 


tumor  peculiar  to  it,  the  odontoma,  which  is  a  dense  mass  made  up  of 
various  tooth  tissues  and  may  be  attached  to  a  tooth  or  be  composed 
of  several  teeth  fused  together.  Sometimes  they  take  the  form  of 
undefined  masses  of  considerable  density,  which  continue  to  grow 
and  develop  into  large  deforming  tmnors.  Salivary  calculi  must  be 
mentioned  in  any  consideration  of  the  teeth.  They  cast  dense  round 
or  oval  shadows  seen  in  the  position  of  the  salivary  glands  or  ducts. 
When  projected  upon  the  mandible  in  oblique  views  they  must 
not  be  mistaken  for  areas  of  density  in  the  bone.  The  shadows  of 
calcified  glands  often  appear  in  tooth  plates.     They  are  spotted 


96  SKULL 

mulberry-like  shadows,  characteristic  of  calcified  glands  anywhere. 
The  tip  of  an  nnnsually  long  styloid  process  may  be  projected  upon 
the  upper  molar  region  and  be  mistaken  for  an  extra  tooth  root  or 
supernumerary  tooth. 

BIBLIOGEAPHY. 

Heuer,  G.  J.,  and  Dandy,  ^Y.  E.:  Roentgenography  in  the  locahzation  of  brain 
tumors,  Johns  Hopkins  Hosp.  Bull.,  1916,  xxvii,  p.  311. 

Veasey,  C.  A.:    Osteorfia  of  sinuses,  Ann.  Ophth.,  1916,  xxv,  p.  699. 

Probert,  C.  C:   Osteoma  of  sinuses,  Jour.  Michigan  Med.  Soc,  1916,  xv,  p.  304. 

Boas,  E.  P.,  and  Scholz:  Calcification  of  the  pineal  gland.  Arch.  Int.  Med.,  1918, 
xxi,  p.  66. 

Stewart,  W.  H.,  and  Luckett,  W.  H.:  Roentgen  diagnosis  of  fracture  of  the  skull, 
Arch.  Radiol.,  1915-16,  xx,  p.  1.50. 

Gould  and  Le  Wald:    Chloroma,  Med.  Rec,  1916,  p.  7.57. 

Sharpe,  W.:    Oxycephaly,  Am.  Jour.  Med.  Sc,  1916,  cli,  p.  840. 

Osgood:    Lesions  of  tibial  tubercle,  British  Med.  Surg.  Jour.,  January  29,  1903. 

Mauclaire,  P.:  Absence  d'ossification  du  cartUage  de  conjugaison  des  deux  tuber- 
osities tibiales  anterieures  chez  un  adulte,  Bull,  et  Mem.  Soc.  de  chir.  de  Paris,  1915, 
xli,  p.  2457. 

Gushing,  Harvey  P.:    Pituitary  body  and  its  disorders,  Philadelphia,  1912. 

Thoma,  K\irt.  H.  :    Oral  abscesses,  Boston,  1916. 


CHAPTER   VI. 
JOINTS,  TENDONS  AND  BURS.E. 

There  is  as  yet  no  really  satisfactory  classification  of  the 
joint  diseases  because  of  the  lack  of  accurate  pathological  knowl- 
edge. Probably  the  best  one  so  far  proposed  is  that  of  Barker, 
upon  which  the  following  outline  is  based.  It  must  be  insisted 
that  no  hard-and-fast  adherence  to  the  general  types  described 
below  is  possible.  Atypical  joints  and  those  which  fall  under  more 
than  one  heading  are  often  observed.  In  the  study  of  a  pathological 
joint,  the  following  features  should  be  carefully  noted:  (1)  Peri- 
articular swelling  in  the  soft  parts,  (2)  effusion  in  the  joint,  (3) 
erosion  of  cartilage  as  evidenced  by  diminution  of  the  joint 
space,  (4)  changes  in  density  of  the  bone,  (5)  outgrowths  of  new  bone 
formation  and  (6)  the  joints  in^'olved.  Probably  the  commonest 
form  of  arthritis  is  the  hypertrophic,  which  occurs  in  individuals 
over  forty,  more  often  men.  Its  characteristic  feature  is  the  pres- 
ence of  spurs  or  lipping  on  the  margins  of  articular  surfaces,  which 
include  vertebral  bodies.  These  outgrowths  are  dense  with  sharp 
edges  and  in  some  cases  cause  fixation  of  a  joint  by  interlocking 
or  fusion.  There  is  no  fluid  in  the  joint  unless  it  has  been  recently 
injured.  There  is  no  loss  of  articular  cartilage  and  no  decalcification 
of  adjacent  bone.  It  may  attack  any  joint,  usually  the  larger,  and 
is  very  common  in  the  spine.  These  joints  may  exist  for  a  consider- 
able length  of  time  without  giving  many  symptoms  but  they  are 
apparently  points  of  lowered  resistance,  for  after  injur}'  they  may 
be  the  seat  of  acute  painful  reactions  which  are  entirely  out  of  pro- 
portion to  the  injury  and  would  not  have  occurred  in  a  normal 
joint.  This  condition  is  continually  being  encountered  in  industrial 
accident  work. 

Gout. — Gout  is  less  common  but,  like  the  first  type,  occurs  after 
forty,  more  frequently  in  men  than  in  women.  In  a  typical  case  it 
presents  peri-articular  swelling  and  very  characteristic  punched-out 
areas  in  the  bones  at  the  margins  of  the  articular  surfaces.  These 
holes  are  sharply  cut  and  vary  from  one  to  several  millimeters  in 
diameter,  in  severe  cases  causing  complete  destruction  of  an  articular 
7 


98 


JOINTS,  TENDONS  AND  BURSM 


end  of  the  bone.  There  is  httle  effusion  in  the  joint,  erosion  of  the 
cartilages  occurs  only  in  the  late  severe  cases  and  there  is  no  decal- 
cification. Usually  some  slight  hypertrophic  spurs  are  present.  It 
ordinarily  occurs  in  the  phalangeal  joints  of  the  hands  and  feet, 
but  may  affect  the  carpus  or  tarsus  and  in  rare  cases  a  large  joint, 
such  as  the  knee,  simulating  here  an  early  Charcot  joint  from  the 


Fig.  71.— Gout. 


amount  of  destruction  and  new  bone  formation  which  takes  place. 
In  the  early  stages  before  the  punched-out  areas  become  evident 
it  may  be  mistaken  for  a  hypertrophic  arthritis.  It  is,  of  course, 
accompanied  by  other  clinical  evidence  of  the  disease. 

Charcot  Joints. — A  striking  picture  which  occurs  in  patients  with 
tabes  or  syringomyelia  is  seen  usually  in  middle  age.  There  is  tre- 
mendous swelling  of  the  soft  parts,  destruction  of  articular  surfaces. 


ATROPHIC  ARTHRITIS  99 

amounting  to  complete  disorganization,  and  large  irregular  masses 
of  calcified  material  scattered  throughout  the  joint.  There  is  no 
decalcification  of  bone.  Its  commonest  sites  are  the  knee,  hip, 
ankle  and  spine.  Conditions  which  may  be  confused  with  it  are 
(1)  gout,  which  is  rare  in  large  joints  and  always  involves  the  smaller 
ones  in  addition;  (2)  loose  bodies  in  joints,  in  which  case  the  cal- 
cified masses  are  small,  dense  and  few  in  number,  and  the  joint 


Fig.  72. — Charcot  joint. 

surfaces  are  not  disturbed  except  that  the  point  of  origin  of  the 
fragment  may  be  evident  in  a  chipped-off  area  on  the  inner  condyle 
of  the  femur;  or  (3)  calcified  hematomata,  in  which  the  calcification 
is  much  more  extensive.     The  joint  surfaces  are  intact. 

Atrophic  Arthritis. — Atrophic  arthritis  is  more  common  in  women 
and  it  is  seen  between  the  ages  of  twenty-five  and  forty-five.  It 
begins  with  periarticular  swelling  followed  by  gradual  loss  of 
articular  cartilage,  sho\Mi  by  narrowing  of  the  joint  space  and  by 


100  JOINTS,  TENDONS  AND  BURSM 

severe  atrophy  of  the  soft  parts,  and  decalcification  of  bone.  There 
is  no  tendency  to  new  bone  or  spur  formation.  The  process  extends 
over  a  period  of  years,  ending  typicality  in  complete  ankylosis. 

Infectious  Arthritis.^ — Infectious  arthritis  attacks  any  joint  at  any 
age.  Its  forms  are  extremely  varied  owing  to  the  number  of  causa- 
tive agents.  The  most  common  types  are  pyogenic,  gonorrheal, 
tuberculous  and  syphilitic. 


Fig.  73. — Infectious  arthritis  of  the  knee-joint.     An  early  case. 

Pyogenic  Arthritis. — Pyogenic  arthritis  is  usually  due  to  staphylo- 
C3CCUS,  streptococcus  or  pneumococcus.  The  acute  forms  attack  one 
or  many  joints  which  show  soft  tissue  swelling  and  effusion  in  the 
synovial  cavity.  The  process  may  then  subside  with  disappearance 
of  these  signs.  If  it  persists  for  several  weeks,  decalcification  of  the 
articular  ends  of  the  bones  will  occur  and  there  may  be  erosion  of 
cartilage  with  narrowing  of  the  joint  space.  Later,  as  repair  begins, 
hypertrophic  changes  may  make  their  appearance  at  the  margins 


TUBERCULOSIS 


101 


of  the  articular  surfaces  or  the  cartilage  may  be  entirely  destroyed 
and  ankylosis  result  when  healing  is  complete. 

Gonorrheal  Arthritis. — Gonorrheal  arthritis  is  usually  monarticular 
but  it  may  be  indistinguishable  roentgenologically  from  other 
pyogenic  joints.  However,  there  are  two  findings  in  addition  to 
those  of  pyogenic  infection  which  are  very  suggestive  of  Xeisserian 
origin.  One  is  a  localized  destruction  of  the  cartilage  on  the  under 
surface  of  the  patella  which  sinks  in  towards  the  condyles  of  the 
femur.    Subsequently  hypertrophic  changes  appear  on  its  margins 


Fig.  74. — Hypertrophic  arthritis  of  the  knee-joint. 


and  on  the  adjacent  areas  of  the  femur.  The  "second  is  the  occur- 
rence of  small  localized  areas  of  rarefaction  in  the  bone  at  the  junc- 
tion of  articular  surfaces  and  cortex.  Another  result  of  this  infec- 
tion is  the  development  of  spurs  upon  the  os  calcis  which  tend  to 
grow  out  along  the  plantar  fascia.  These  spurs  may  be  the  result 
of  the  activity  of  streptococcus  but  the  great  majority  are  gonorrheal. 
Tuberculosis. — Tuberculosis  is  more  common  in  children.  It 
causes  slight  enlargement  of  the  soft  parts,  efl'usion  in  the  capsule, 
and  general  haziness  and  muddiness  of  the  entire  joint  area.  There 
is  extreme  decalcification  so  that  the  outlines  of  the  bones  mav  be 


102 


JOINTS,  TENDONS  AND  BUBSM 


Fig.  75. — -Tuberculosis  of  the  knee-joint. 


Fig.  7G. — Tuberculosis  of  the  hip.     An  early  case. 


TUBERCULOSIS 


103 


Fig.   77. — The   same   case   as   Fig.   76,   two  j'ears  later.     The   process  is   now  well 
advanced  and  quite  typical. 


Fig.  78. — -The  same  case  as  Fig.  76,  three   years    after   the  first  oxainiiintion.      The 
disease  is  now  arrested. 


104 


JOINTS,  TENDONS  AND  BURSM 


reduced  to  a  thin  pencilled  white  line.  Enlargement  and  squaring 
of  the  epiphyses  are  seen  and  later  more  or  less  destruction  of  joint 
surfaces,  and  interference  with  the  growth  of  the  bone.  There  is 
no  new  bone  formation.  The  occurrence  of  periosteal  reaction  and 
bony  ankylosis  in  these  joints  is  the  result  of  secondary  infection. 
During  the  process  of  repair  there  is  increase  in  density  due  to 
deposit  of  lime  salts.  Caries  sicca  is  seen  most  commonly  in  the 
shoulders  in  adults.  It  shows  a  chronic  ragged  erosion  of  the 
articular  surfaces,  no  soft  tissue  swelling,  no  effusion  and  no 
decalcification. 


Fig.  79. — Gumma  ol  \\w  .-.piuc. 


Syphilis. — Syphilis  may  be  seen  at  any  age  and  it  is  manifested 
by  increased  density  in  the  soft  tissue  and  the  occurrence  of  a 
slight  periostitis  at  the  junction  of  the  periosteum  and  synovial  mem- 
brane ;  occasionally  by  destruction  of  articular  surfaces,  particularly 
those  of  the  small  bones,  such  as  carpus  and  tarsus,  and  by  local 
lesions  in  the  epiphyses  suggesting  tuberculous  foci.  In  some  cases, 
as  the  result  of  chronic  low-grade  inflammation  in  the  synovial 
membrane,  low,  rounded  hypertrophic  ridges  will  appear  at  the 
margins  of  the  articular  surfaces. 

Villous  Arthritis. — Villous  arthritis  consists  of  a  thickening  in  the 
soft  parts    due  to   overgrowth  of   synovial    fringes.     It    may  be 


Fig.  so. — Syphilis  of  the  knee-joint. 


Fig.  81. — Multiple  calcified  bodies  in  the  knee-joint. 


106 


JOINTS,  TENDONS  AND  BURSM 


seen  in  lateral  views  of  the  knee,  where  the  posterior  portion 
of  the  capsule  is  occupied  by  a  mass  of  slightly  greater  density  than 
normal,  and  where  a  stringy,  fan-shaped  shadow  can  be  made  out 
radiating  anteriorly  between  the  condyles  of  the  femur  and  tibia. 
Hemophilia. — AVhen  the  joints  are  involved  in  this  disease  the 
signs  are  those  of  chronic  joint  irritation  suggesting  tuberculosis. 
There  is  bone  atrophy  amounting  even  to  pencilling  of  the  outlines, 
effusion  into  the  joint  and  moderate  enlargement  and  squaring  of  the 
epiphyses.  At  times  erosion  of  the  articular  ends  of  the  bones  may 
occur,  or  calcification  of  the  blood-clot  within  the  joint. 


Fig.  82. — Hemophilia  with  organizing  blood-clot  in  the  capsule  of  the  elbow-joint. 


Osteochondritis  Desiccans. — Osteochondritis  desiccans  is  charac- 
terized by  the  presence  of  a  mass  of  cartilage  loose  in  the  joint 
whose  site  of  detachment  may  usually  be  made  out  upon  the  articu- 
lar surface  of  the  inner  condyle  of  the  femur.  If  these  loose  pieces 
do  not  calcify  they  are  invisible,  but  fortunately  most  of  them 
do  in  the  course  of  time. 

Osteochondritis  Deformans  (Perthe's  disease). — Osteochondritis 
deformans  is  revealed  by  a  flattening  and  mushrooming  of  the  head 
of  the  femur,  suggesting  tuberculosis  but  without  typical  clinical 
signs.  The  joint  is  not  involved.  There  is  little  bone  atrophy  and 
interference  with  growth  is  not  marked.     It  is   possibly   due  to 


OSTEOCHONDRITIS  DEFORMANS  107 


Fig.  S3. — Osteochondritis  desiccans. 


Fig.  84. — Perthe's  disease.     An  early  case.     Note  the  slight  deformity  of  the 
head  of  the  femur. 


lOS 


JOINTS,  TENDONS  AND  BURSM 


Fig.  85. 


-Perthe's  disease.     The  same  case  as  Fig.  84,  one  year  later, 
is  now  well  marked  and  quite  typical. 


The  process 


Fig.  86. — Perthe's  disease.  Same  case  as  Fig.  84,  three  years  after  the  first 
examination.  The  head  of  the  femur  is  more  dense,  showing  that  repair  is  taking 
place. 


TENDONS  AND  BURSJE 


109 


interference  with  the  blood  supply  of  the  epiphysis.  The  end  result 
of  such  a  process  as  seen  in  adults  is  a  flattening  of  the  head,  which 
is  sometimes  displaced  downward  slightly  on  the  neck. 


TENDONS  AND  BURS-ffi. 

Effusion  or  hemorrhage  in  or  about  these  tissues  is  shown  by  an 
area  of  slightly  increased  density  with  indefinite  margins.  S^Tlo- 
vitis  of  the  Achilles,  quadriceps  or  extensor  longus  pollicis  tendons 
may  occasionally  be  suspected  from  thickening  of  the  shadow  and 
blurring  of  its  ordinarily  sharp  outlines.  Areas  of  increased  density 
seen  in  the  region  of  the  subdeltoid  bursa  maA'  be  true  calcifications 


Fig.  87. — Subdeltoid  bursitis. 


in  the  bursa,  which  are  rare;  accumulations  of  an  opaque  gelatinous 
substance  in  the  bursa;  or,  what  is  more  common,  calcification 
about  the  tendon  of  the  supraspinatus  beneath  it.  Calcification 
may  occur  in  any  bursa  which  has  been  the  seat  of  tramna  or 
infection. 


110  JOINTS,  TENDONS  AND  BURS.E 

BIBLIOGRAPHY, 

Gushing,  H.:  Hereditarj-  ankylosis  of  the  proximal  phalangeal  joints  (sympha- 
langism), Jour.  Nerv.  and  Ment.  Dis.,  1916,  xliii,  p.  445. 

Goldthwait,  J.  E.:  Lumbosacral  articulation,  British  Med.  Surg.  Jour.,  1911, 
clxiv,  p.  365. 

OgUvy:  Subluxations  of  atlas  upon  the  axis.  Am.  Jour.  Orthop.  Surg.,  1914-15, 
xii,  p.  314. 

O'Eeilly,  A.:   Joint  sj-philis.  Am.  Jour.  Orthop.  Surg.,  1913-14,  xii,  p.  431. 

Brickner,  W.  M.:    Subacromial  bursitis,  Am.  Jour.  Surg,.  1916,  xxx,  p.  108. 

Dunlop:  Deposit  simulating  subacromial  bursitis.  Am.  Jour.  Orthop.  Surg.,  1916, 
xiv,  p.  102. 

Brickner,  W.  M.:    Subacromial  bursitis,  Jour.  Am.  Med.  Assn.,  1916,  Ix^d,  p.  912. 

Stein:    Syphilitic  arthritis,  Med.  Rec,  1915,  p.  472. 

Skillern:    Joint  lues,  Internat.  Clin.,  1914,  xxiv,  p.  192. 

Whitelocke:    Loose  joint  bodies,  British  Jour.  Surg.,  1914,  p.  650. 

Legg,  A.  T.:  An  obscure  affection  of  the  hip-joint,  British  Med.  Surg.  Jour., 
1910,  clxii,  p.  202. 

Berrj-,  John  McW. :  Roentgenological  shadows  associated  -ndth  subdeltoid  bursitis. 
Am.  Jour.  Orthop.  Surg.,  1916,  xiv,  p.  476. 

Scott,  S.  G.:  Myositis  ossificans,  Charcot's  joint  associated  with.  Arch.  Radiol., 
1917,  xxi,  p.  239. 

Barker,  L.  F. :  Differentiation  of  diseases  included  under  chronic  arthritis,  Am. 
Jour.  Med.  Sc,  l(fl4,  cxhdi,  p.  1. 

Legg,  A.  T. :  Osteochondral  trophopathj-  of  the  hip-joint,  Surg.,  Gynec.  and  Obst., 
1916,  xxii,  p.  307. 

Freiberg,  A.  H.:  Hemophilia  affecting  the  knee.  Lancet,  Chn.,  1916,  exv,  p.  588.    ■ 

Brickner,  W.  M.:  Cause  of  Roentgen  shadow  in  eases  of  subacromial  bursitis. 
Am.  Atlas  Stereoroent.,  1916,  i,  p.  34. 

Henderson,  M.  S.:  Loose  bodies  in  the  knee-joint,  Am.  Jour.  Orthop.  Surg.,  1916, 
xiv,  p.  265. 

Brickner:  Prevalent  fallacies  concerning  subacromial  bursitis,  Am.  Jour.  Med.  So., 
1915,  p.  540. 

Carnett,  J.  B.:  Typhoid  .spine,  with  a  report  of  cases.  Am.  Surg.,  Philadelphia, 
1915,  Ixi,  pp.  456-471. 

Perthes,  G. :  L^eber  osteochondritis  deformans  juvenalis,  Arch.  f.  klin.  Chir.,  1913, 
ci,  p.  779. 

Bracket,  E.  G.,  and  Hall:  Osteochondritis  desiccans.  Am.  Jour.  Orthop.  Surg.,  1917, 
XV,  p.  79. 


CHAPTER   VII. 
THE  CHEST. 

The  shadow  of  the  chest  may  be  divided  into  (1)  that  of  the 
thoracic  wall,  (2)  a  central  shadow  consisting  of  supraposed  ster- 
num, heart,  great  vessels,  mediastinum  and  spine,  (3)  the  diaphragm 
and  (4)  the  lung  fields. 

Pathological  processes  in  the  thoracic  wall  may  consist  of  injuries 
to  the  ribs,  of  infections  and  of  tumors.  They  are  similar  to  the  same 
processes  elsewhere.  Occasionally  there  is  an  emphysema  of  the 
soft  tissues  usually  associated  with  fracture  of  the  ribs  or  surgical 
interference.  The  plate  is  very  striking  and  shows  the  presence  of 
dark  areas  representing  air  scattered  through  the  muscles  and  sub- 
cutaneous tissue. 

The  central  shadow  is  concerned  with  the  outlines  of  the  thymus 
and  thyroid,  of  mediastinal  masses  and  with  the  shape,  size  and 
position  of  the  shadows  of  the  great  vessels  and  pericardium.  Nor- 
mally the  thyroid  and  thymus  are  not  visible  in  a  chest  plate.  A 
substernal  thyroid  or  enlarged  thymus  appears  as  a  dilatation  of 
the  upper  end  of  the  central  shadow  with  sharp  margins  which 
extend  upward  beyond  the  clavicles.  In  children,  an  enlarged  thymus 
gives  a  particularly  characteristic  shadow.  It  is  roughly  quad- 
rangular with  rounded  lower  corners  and  sharp  margins  which  extend 
straight  down  from  above  the  clavicles  and  overlap  the  shadow  of 
the  heart  and  vessels.  It  is  less  dense  than  other  tumors  and  is 
easily  overlooked.  In  our  experience,  lateral  and  oblique  views  are 
of  little  value  in  its  recognition. 

Thyroid. — The  thyroid,  when  intrathoracic,  shows  as  a  dense, 
sharply  defined  shadow  extending  down  and  overlapping  the  great 
vessels.  It  may  be  differentiated  from  thymus  and  other  medias- 
tinal tumors  by  the  fact  that  it  moves  with  deglutition. 

Mediastinal  masses  may  be  due  to  enlargements  of  the  medias- 
tinal glands,  growths,  aneurysms,  vertebral  abscesses  and  dilatations 
of  the  esophagus. 

Enlargement  of  the  glands  is  usually  due  to  tuberculosis, 
Hodgkin's  disease  or  malignancy.  Their  outline  is  sharp  and  irregu- 
lar or  lobulated  and  the  process  is  usually  bilateral.  They  seldom 
show  pulsation  although  large  masses  may  transmit  the  impulse 


112 


THE  CHEST 


of  heart  or  aorta.  By  careful  fluoroscopic  examination  it  is  some- 
times possible  to  separate  their  shadow  from  that  of  the  aorta  or 
to  demonstrate  a  normal  aorta. 

The  most  common  tumors  are  lymphosarcoma,  Hodgkin's  disease, 
and  carcinoma,  primary  or  metastatic.  They  produce  dense 
shadows  with  sharply  defined  borders  and  may  displace  or  com- 
press the  surrounding  organs,  often  showing  transmitted  pul- 
sation. They  may- be  mistaken  for  aneurysm,  but  careful  study 
with  the  fluoroscope  and  plates  at  difl:'erent  angles  will  usually 


Fig.  88. — Malignant  tumor  of  the  mediastinum,  resembling  aneurysm. 


dift'erentiate  them .  In  lymphosarcoma  and  Hodgkin's  disease,  glands 
elsewhere  in  the  bod}'  are  usually  involved  and  the  masses  tempo- 
rarily disappear  with  great  rapidity  under  roentgen  radniatio.^ 
Primary  malignancy  is  rare.  It  usually  occurs  as  a  unilateral, 
irregular  enlargement  of  the  hilus  shadow  which  shows  a  tendency 
to  grow  in  the  direction  of  the  affected  bronchi.  Metastatic  malig- 
nancy, in  addition  to  the  enlargement  of  the  hilus  shadows,  may 
show  the  characteristic,  annular,  sharply  defined  patches  through  the 
lung  fields.     Teratomata  may  invade  the  mediastinum  in  rare  cases, 


THYROID 


113 


Fig.  89. — The  same  case  as  Fig.  88.     After  a  series  of  treatments  with  .r-rays  the 
decrease  in  the  size  of  the  tumor  rules  out  aneurysm. 


Fig.  90. — The  same  case  as  Fig.  88,  one  year  after  the  first  examination. 


114 


THE  CHEST 


causing  an  increase  in  the  Avidth  of  the  central  shadow  without 
distinguishing  characteristics.  Dermoid  cysts  may  occur  and 
should  be  recognized  by  their  cystic  wall  and  the  fact  that  they 
arise  from  the  mediastinum.  Lipomata  may  also  develop  in  this 
region. 

THE  HEART  AND  GREAT  VESSELS. 

In  an  examination  of  the  heart  we  should  obtain  the  following 
data:   Size,  shape,  its  movements  with  respiration,  pulsation  of  the 


Fig.  91. — Teleradiogram  of  the  normal  heart  and  great  vessels: 
No.  I  on  the  right  is  the  ascending  aorta. 
No.  II  on  the  right  is  the  right  auricle. 
No.  1  on  the  left  is  the  aortic  arch. 
No.  2  on  the  left  is  the  pulmonarj-  arteiy. 
No.  3  on  the  left  is  the  left  auricle. 
Xo.  4  on  the  left  is  the  left  ventricle. 


various  chambers,  and  any  change  of  shape  which  may"  occur  with 
change  in  position  of  the  patient.     "We  should  also  note  the  size 


THE  HEART  AND  GREAT  VESSELS 


115 


Fig.   92. — Tracing  showing  the  shape  of  the  normal  heart   and  great  vessels  and 
the  points  from  which  measurements  are  taken.      (From  Groedel.) 


Fig.    93. — A   tracing   showing  the   normal  respiratory   excursion   of   the   heart    and 
diaphragm  during  quiet  and  forced  breathing.     Patient  is  standing. 


116 


THE  CHEST 


and  shape  of  the  aorta  in  both   its  anteroposterior  and  lateral 
diameters. 

This  data  may  be  obtained  by  means  of  orthodiagraphy  or  by 
combination  of  tele-roentgenology  and  fluoroscopic  examination. 


Fig.  94. — The  drop  heart  of  the  ptotic. 


The  advantages  of  orthodiagraphy  are  its  accuracy  in  the  hands 
of  experts  and  ability  to  outline  the  apex.  Its  disadvantages  are: 
the  time  required  to  perfect  a  technic,  and  constant  chance  for  error 
due  to  the  personal  limitations  of  the  operator. 


Fig.  95. — The  enlargement  of  the  left  ventricle  and  aortic  regurgitation. 


Tig.  96. — The  same  case  as  Fig.  95,  but  taken  at  two  instead  of  six  feet.     Note  the 
distortion  of  the  enlarged  left  ventricle. 


lis 


THE  CHEST 


Tele-roentgenology  has  the  advantage  of  ehminating  the  personal 
equation  and  of  producing  a  permanent  record.  Its  disadvantages 
are:  the  shghtly  higher  cost  and  the  difficulty  of  demonstrating 
the  apex  and  the  junction  of  the  left  auricle  with  the  left  ventricle. 
These  points  are  of  importance,  as  without  them  all  the  measure- 
ments cannot  be  obtained. 


7.6 

' :; 

. 

h/ 

/ 

/ 

^x^ 

A 

/ 

\A> 

/ 

^'^\ 

/ 

4-            \ 

w 

X*^ 

7 

X^cf 

/         8.S 

/2.6           \. 

'    / 

t 

^-  2i  .1-^                              \^^^ 

Fig.  97.— The  dilated  heart. 


By  fluoroscopy  it  is  possible  to  obtain  a  fairly  accurate  outline 
of  the  shape  and  position  of  the  heart  shadow  and  of  its  movements 
with  respiration ;  also  of  any  change  of  shape  which  may  occur  with 
change  of  position.  By  combining  this  data  with  the  data  obtained 
from  a  plate  taken  at  a  seven-foot  target  film  distance,  all  the 
required  findings  are  present. 

This  method  of  combined  fluoroscopy  and  tele-roentgenography 
has  been  in  use  at  the  Massachusetts  General  Hospital  for  the  past 
five  years  and  has  proved  quite  satisfactory.  The  fluoroscopic 
observation  is  made  first.    The  patient  is  placed  in  the  upright  posi- 


THE  HEART  AND  GREAT  VESSELS 


119 


tion  behind  a  fixed  screen.  The  focal  spot  of  the  tube  is  at  a  distance 
of  24  inches  from  the  screen.  From  2  to  3  ma.  at  60,000  volts  gives 
a  good  image. 

A  thin  plate  of  glass  in  front  of  the  fluoroscopic  screen  serves  as 
a  receptacle  for  the  tracing  which  is  made  of  the  outline  of  the  heart 
and  gi'eat  vessels  during  normal  breathing,  forced  inspiration  and 
forced  expiration. 


s.s 

7.2/               ^ 

/ 

\ 

Fig.  98. — Mitral  disease. 


The  patient  is  then  rotated  to  the  left  so  that  his  right  chest  is 
in  contact  with  the  screen,  and  the  posterior  mediastinal  space  with 
the  arch  of  the  aorta  are  studied.  By  changing  the  position  of  the 
patient  slightly,  the  size  of  the  shadow  of  the  aorta  will  be  seen  to 
grow  larger  or  smaller.  The  smallest  possible  shadow  which  can  be 
obtained  represents  the  true  diameter  of  the  aorta  plus  the  amount 
of  magnification  due  to  its  distance  from  the  screen. 

A  tracing  is  made  of  the  aorta  in  this  position  for  comparison 


120 


THE  CHEST 


with  the  tracing  made  in  the  anteroposterior  view.  From  the  two 
tracings  an  estimate  can  be  made  of  the  amount  of  overlapping  of 
the  ascending  and  descending  aorta.  The  glass  with  its  tracing  is 
removed  and  the  pulsation  of  the  various  chambers  of  the  heart 
is  studied  and  compared.  If  there  is  anything  in  the  findings 
which  suggests  a  pericardial  effusion,  the  patient  is  examined  in  the 
prone  position. 


Fig.  99. — The  water-bottle  shape  of  the  heart  shadow  seen  in  pericardial 
effusion  with  the  patient  upright. 


After  the  fluoroscopic  observations  are  completed,  a  mark  is  placed 
on  the  patient's  chest  opposite  the  center  of  the  heart  shadow  to 
serve  as  a  point  upon  which  to  focus  the  tube  for  the  plate  which  is 
taken  with  the  patient  standing.  The  focal  spot  of  the  tube  should 
be  at  a  distance  of  at  least  six  feet  from  the  plate. 

Special  care  must  be  taken  so  to  place  the  patient  that  the  central 
rays  from  the  tube  pass  through  the  chest  at  right  angles  to  its 


THE  HEART  AND  GREAT  VESSELS  121 

transverse  diameter.  At  this  distance  a  small  amount  of  displace- 
ment of  the  tube  to  the  right  or  the  left  from  the  median  line  does 
not  appreciably  distort  the  heart  shadow,  but  a  slight  rotation  of 
the  patient  does  produce  definite  distortion. 

In  stout  patients  it  is  better  to  have  the  plate  in  contact  with  the 
chest  wall  and  the  patient  standing  erect.    If  the  plate  is  placed  at 


Fig.  100. — The  same  ca.se  as  Fig.  99,  but  taken  with  the  patient  prone.  Note 
the  change  in  the  shape  of  the  heart  shadow,  due  to  the  .shifting  of  the  fluid  within 
the  pericardium. 


right  angles  to  the  central  ray  from  the  tube,  its  upper  portion 
may  be  some  distance  from  the  chest  wall;  and  as  we  are  not 
dealing  with  absolutely  parallel  rays,  a  slight  amount  of  magnifica- 
tion of  the  aorta  will  result. 

On  the  other  hand,  if  the  patient  is  allowed  to  lean  forward  to 
bring  the  chest  entirely  in  contact  with  the  plate,  there  will  be  a 
certain  amount  of  apparent  sagging  of  the  contents  of  the  chest. 

The  time  of  exposure  should  be  sufficiently  long  to  cover  one  full 


122 


THE  CHEST 


heart  cycle,  so  that  the  shadow  obtained  will  be  the  shadow  of  the 
heart  in  diastole.  Where  very  rapid  exposures  are  made  the  result- 
ing picture  may  represent  the  heart  either  in  systole  or  diastole  or 
at  some  phase  between.  The  period  of  diastole  is  the  one  from  which 
estimates  of  the  heart  size  are  made. 


V 

'■V 
6 

■y 

S  6 

• 

'5.5                        //T^x                   ^ 

Fig.  101. — The  triangular  shape  and  indefinite  outline  of  the  heart  seen  in  adhesive 

pericarditis. 


Therefore,  it  is  evident  that  a  relatively  long  exposure  is  desirable. 
The  patient  should  be  instructed  to  keep  still,  but  it  is  not  desirable 
for  him  to  take  a  deep  breath  nor  is  it  necessary  to  hold  the  breath. 
The  amount;  of  movement  of  the  heart  shadow  in  normal  respiration 
is  very  slight.  ^Yith  deep  inspiration  there  is  a  definite  change  both 
in  the  shape  and  size.  The  amount  of  current  passed  through  the 
tube  may  vary  according  to  the  type  of  apparatus  available.  About 
the  same  degree  of  penetration  should  be  used  as  in  frontal  sinus 
work.    Intensifying  screens  are  desirable. 

After  the  plates  are  developed  and  dried  the  measurements  are 


THE  HEART  AXD  GREAT  VESSELS  123 

made  from  them  according  to  the  plan  adopted  by  Groedel.  This 
plan  includes  six  points  from  which  measurements  are  taken:  three 
on  the  right  and  three  on  the  left  side  of  the  heart  shadow.  The 
upper  point  on  the  right  is  at  the  junction  of  the  heart  shadow  with 
that  of  the  great  vessels.  The  second  point  on  the  right  is  at  the 
furthest  point  of  the  heart  shadow  to  the  right,  and  the  lowest  point 
is  at  the  junction  of  the  heart  shadow  with  the  diaphragm.  On  the 
left,  the  highest  point  is  at  the  junction  of  the  left  auricle  with  the 
left  ventricle.  The  second  point  is  at  the  greatest  distance  to  the 
left,  and  the  third  point  is  at  the  heart  apex.  A  line  is  then  drawn 
along  the  center  of  the  spinal  column.  This  may  be  used  as  the 
midline. 

The  greatest  distance  to  the  right  and  the  greatest  distance  to 
the  left  from  this  line  are  easily  obtained.  Their  sum  represents  the 
greatest  transverse  diameter  of  the  heart  shadow.  A  line  drawn 
from  the  highest  point  on  the  right  to  the  heart  apex  represents  the 
total  length  of  the  heart;  and  lines  drawn  at  right  angles  to  it, 
one  to  the  highest  point  on  the  left  and  one  to  the  lowest  point  on 
the  right,  give  us  the  diameter  of  the  base. 

By  comparing  these  figures  and  the  shape  of  the  heart  and  aorta 
with  the  respiratory  movements  and  pulsations  as  recorded  on  the 
tracing,  the  conclusions  are  made. 

To  interpret  the  findings  one  must  have  a  thorough  knowledge 
of  the  anatomy  of  the  heart  and  great  vessels,  and  of  the  normal 
radiographic  shadow. 

'Normally,  the  central  shadow  approximates  the  outline  in  Fig.  91. 
At  the  top,  on  the  left  side,  the  edge  of  the  arch  of  the  aorta  appears 
with  the  descending  aorta  extending  downward  from  it;  below  it 
the  slight  prominence  of  the  pulmonary  artery  and  the  small  left 
auricular  appendage  in  the  angle  between  it  and  the  ventricle.  The 
rounded  mass  of  the  ventricle  makes  up  the  largest  part  of  the 
shadow  and  disappears  below  the  diaphragm  line.  The  location  of 
the  apex  is  a  matter  of  considerable  uncertainty,  as  it  A'aries  with 
the  size,  shape  and  position  of  the  heart  and  of  the  patient,  and  the 
position  and  shape  of  the  diaphragm. 

The  right  border  begins  at  the  top  with  the  poorly  defined  shadow 
of  the  superior  vena  cava  above  and  overlapping  the  ascending 
aorta,  which  is  sometimes  indented  by  the  right  bronchus  in  its 
lower  portion.  The  line  then  curves  outward  over  the  right  auricle 
to  join  the  right  diaphragm  at  an  acute  angle  at  the  apex  of  which 
the  inferior  vena  cava  is  sometimes  apparent. 


124  THE  CHEST 

Diseases  of  the  Heart  Valves. — Diseases  of  the  heart  valves  are 
accompanied  by  an  enlargement  of  the  corresponding  chamber  or 
chambers.  For  instance,  in  mitral  regurgitation,  the  enlargement  of 
the  shadow  is  to  the  right  and  across  the  base  because  of  the  changes 
in  the  left  auricle  and  the  right  ventricle  (see  Fig.  98) . 

Aortic  Disease. — The  enlargement  is  almost  entirely  to  the  left. 
A  knowledge  of  the  physiology  and  pathology  of  the  heart  will 
enable  one  to  accurately  interpret  these  lesions  from  the  changes 
in  the  shape  of  the  heart  shadow. 

Auricular  Fibrillation. — Auricular  fibrillation  may  be  demonstrated 
by  the  tremendous  enlargement  of  the  shadow  of  the  auricles  and 
absence  of  visible  pulsation  in  them.  In  certain  of  these  cases  the 
heart  shadow  seems  to  rock. 

Heart  Block. — In  this  condition,  if  the  pulsation  is  not  too  rapid, 
it  is  possible  to  compare  the  beats  of  the  auricle  with  those  of  the 
ventricle  and  determine  their  respective  rates. 

Dilatation. — Dilatation  is  seen  as  a  general  enlargement  of  the 
heart  shadow  with  weak  pulsation  and  an  absence  of  the  rounding 
of  the  apex  seen  in  hypertrophy. 

Congenital  Abnormalities. — Congenital  abnormalities  give  rise  to 
changes  in  shape  and  abnormal  areas  of  pulsation.  Here  again  the 
knowledge  of  the  anatomical  and  pathological  variations  of  the  heart 
and  great  vessels  will  enable  one  to  arrive  at  a  diagnosis  from  their 
appearance  on  the  plate  or  screen. 

Pericardial  Effusion. — With  fluid  in  the  pericardium  the  heart 
shadow  tends  to  become  more  triangular  in  shape.  When  the 
patient  is  prone  there  is  an  increase  in  the  width  at  the  apex  of  the 
triangle,  and  when  upright  an  increase  at  the  base,  or  it  may  assume 
a  water-bottle  shape.  The  cardio-hepatic  angle  is  seldom  obliterated, 
although  it  may  be  so  to  percussion.  Pulsation  is  considerably 
diminished.  In  obtaining  the  shape  of  the  heart  in  different  posi- 
tions for  comparison,  it  is  not  wise  to  depend  on  screen  observa- 
tions alone.  Either  a  careful  tracing  or  plates  taken  at  a  distance 
of  seven  feet  should  be  made  and  the  outlines  thus  obtained 
superimposed. 

Adhesive  Pericardium. ^It  has  been  noted  in  a  small  group  of 
cases  that  the  respiratory  excursion  of  the  heart  is  limited.  There 
is  also  apt  to  be  some  haziness  in  outline  of  the  heart  shadow  and 
apparent  obliteration  of  the  angle  between  it  and  the  diaphragm. 

Dilatation  of  the  Arch, — The  dilatation  of  the  aorta  as  seen  radio- 
graphically  occurs  most  frequently  as  the  result  of  specific  disease. 


THE  HEART  AND  GREAT  VESSELS  125 

There  may  be  a  slight  amount  of  dilatation  present  in  arterio- 
sclerosis and  cases  with  high  blood-pressm-e. 

Very  large  hearts  seem  to  have  a  relative  enlargement  of  the 
aortic  shadow.  With  a  high  position  of  the  diaphragm  the  aortic 
shadow  is  slightly  wider  than  in  cases  with  a  low  diaphragm. 
Probably  part  of  these  variations  are  due  to  the  difference  in  the 
shape  of  the  aortic  arch.  In  a  wide  arch  there  is  less  overlapping 
of  the  ascending  and  descending  aorta  and  consequently  an  increased 
diameter  of  the  shadow. 

Specific  aortitis  tends  to  appear  first  just  abo^"e  the  aortic  valves 
and  as  the  wall  of  the  aorta  becomes  weakened,  a  bulging  of  this 
area  takes  place.  On  the  plate  or  fluoroscopic  screen  the  position 
of  this  bulge  is  seen  just  above  the  shadow  of  the  right  auricle. 

A  marked  prominence  of  the  aortic  shadow  to  the  right  is  almost 
always  due  to  specific  aortitis.  In  arteriosclerosis  the  calcified 
plaques  in  the  aorta  are  not  visible  unless  extensive.  The  tortuous 
aorta,  however,  does  give  a  definite,  fairly  characteristic  change  in 
the  appearance  of  the  aortic  shadow.  There  is  a  distinct,  sharp 
increase  in  the  upper  part  of  the  shadow  to  the  left. 

Diffuse  dilatation  of  the  aorta  also  occurs  and  is  seen  as  a  general 
enlargement  of  its  shadow.  There  is  much  more  difficulty  in  inter- 
preting this  type  from  roentgen  evidence,  as  the  findings  may  be 
the  result  of  the  changes  in  the  aortic  curve  already  mentioned. 

Aneurysm. — The  size,  position  and  location  of  aneurysms  of  the 
aorta  are  seen  on  the  plate  or  fluoroscopic  screen  in  sharp  contrast 
to  the  surrounding  lung  structure.  Should  the  lesion  occur  in  the 
subclavian  or  vessels  of  the  neck,  which  are  not  in  contact  with  the 
lung  structure,  the  aneurysm  is  invisible. 

Aneurysms  of  the  ascending  aorta  are  seen  to  the  right,  while 
aneurysms  of  the  arch  usually  show  to  the  left  of  the  spine  high  up. 
Aneurysms  of  the  descending  aorta  are  seen  in  the  lower  portion  of 
the  aortic  shadow  to  the  left  and  they  may  be  partially  hidden  by 
the  shadow  of  the  heart.  Large  diffuse  aneurysms  may  appear  as 
a  general  increase  in  the  shadow  of  the  great  vessels. 

The  pulsations  of  aneurysms  are  not  always  seen  on  the  fluoroscopic 
screen.  It  is  extremely  difficult  to  differentiate  between  expansile 
and  transmitted  pulsations,  so  that  the  presence  or  absence  of  pul- 
sation, as  observed  fluoroscopically,  is  not  of  conclusive  value  in 
the  diagnosis.  The  position  of  the  sac  is  of  more  importance.  Its 
outline  should  be  sharply  defined  and  the  shadow  of  the  normal 
aorta  should  not  be  seen  through  it.    Mediastinal  tumors  other  than 


126 


THE  CHEST 


aneurysms  are  usually  less  sharply  defined.  They  may  be  nearer 
the  front  or  back  of  the  chest  than  the  position  of  the  great  vessels, 
or  they  may  occupy  a  position  higher  or  lower  than  is  usually  occu- 
pied by  aneurysms;  and  occasionally  the  shadow  of  a  normal  aorta 
may  be  seen  through  them.  They  are  more  likely  to  displace  the 
heart  and  aorta  than  are  aneurysms. 

The  following  table  worked  out  by  Claytor  and  Merrill^  gives  a 
fairly  good  guide  as-  to  the  measurements  of  the  normal  heart. 

Males  (37  cases). 


Weight,  pounds. 

Cases. 

Mr. 

Ml. 

T.  D. 

L.  D. 

3 

7.0 

10.7 

11.8 

Minimum 

120-129 

3 

3.7 

7.2 

10.9 

12.6 

Average 

4.3 

7.5 

11.3 

13.5 

Maximum 

3.5 

7.5 

Tl.O 

12.0 

Minimum 

130-139 

5 

3.8 

8.0 

11.8 

13.2 

Average 

4.2 

8.5 

12,5 

14.0 

Maximum 

3.4 

7.0 

11.0 

12.0 

Minimum 

140-149 

9 

4.0 

7.7 

11.9 

13.4 

Average 

4.6 

8.4 

13.1 

14.5 

Maximum 

3.2 

7.8 

11.5 

12.5 

Minimum 

150-159 

8 

3.9 

8.4 

12.3 

13.5 

Average 

4.5 

9.0 

13.0 

15.0 

Maximum 

3.7 

8.0 

12.0 

14.0 

Minimum 

160-179 

6 

4.0 

8.2 

12.4 

14.6 

Average 

4.8 

9.0 

13.8 

15.8 

Maximum 

180-200 

6 

3.8 

7.0 

11.0 

14.0 

Minimum 

4.2 

8.7 

12.9 

14.7 

Average 

4.5 

9.7 

13.4 

15.3 

Maximum 

Females  (51  cases). 

Weight,  pounds.  Cases. 


100- 

-109 

110- 

-119 

120- 

-129 

130- 

-139 

140- 

-149 

150- 

-159 

160- 

-175 

14 


19 


Mr. 

Ml. 

T.  D. 

L.  D. 

3.2 

6.7 

9.9 

12.0 

Minimum 

3.3 

6.8 

10.2 

12.1 

Average 

3.5 

7.0 

10.5 

12.3 

Maximum 

3.0 

7.0 

10.0 

11.5 

Minimum 

3.1 

7.6 

10.7 

11.9 

Average 

3.2 

8.0 

11.1 

12.4 

Maximum 

2.3 

6.4 

10.2 

10.5 

Minimum 

3.5 

7.5 

11.0 

12.2 

Average 

4.2 

8.6 

12.2 

13.8 

Maximum 

3.0 

6.4 

9.6 

11.2 

Minimum 

3.4 

7.8 

11.2 

12.4 

Average 

4.0 

8.8 

12.6 

13.3 

Maximimi 

2.6 

7.0 

10.0 

12.2 

Minimum 

3.5 

7.6 

11.1 

12.7 

Average 

4.1 

8.3 

11.8 

13.2 

Maximum 

3.1 

7.6 

10.9 

12.3 

Minimum 

3.6 

8.0 

11.6 

12.9 

Average 

4.8 

9.3 

12.8 

14.2 

Maximum 

3.5 

6.5 

10.6 

11.8 

Minimum 

3.8 

7.9 

11:7 

12.6 

Average 

3.8 

8.5 

12.3 

13.0 

Mean 

4.1 

9.0 

12.8 

13.2 

Maximum 

J  Claytor  and  Merrjll:    Am.  Jour.  Med.  Sc,  1909,  New  Series,  cxxxviii,  p.  554. 


THE  HEART  AND  GREAT  VESSELS 


127 


Fig.   102. — A  tracing  showing  the  limited  respiratory    movements  of  the  heart  in 

adhesive  pericarditis. 


Q.l 


Fig.  10-3. — Dilatation  of  the  ascending  aorta,  due  to  specific  aortitis.     The  aorta  is 
partially  hidden  by  the  shadow  of  the  right  auricle. 


128 


THE  CHEST 


Perivertebral  or  Mediastinal  Abscess. — Perivertebral  abscess  will 
usually  give  a  more  or  less  fusiform  shadow  appearing  on  both 
sides  of  the  central  shadow  unless  it  occurs  behind  the  heart.  It 
must  not  be  confused  with  the  shadow  of  the  aorta.  Inasmuch  as 
they  practically  always  result  from  a  lesion  in  the  spine,  the  recog- 
nition of  a  destructive  process  in  the  vertebrtne  is  of  considerable 
aid  in  the  dias'nosis. 


Fig.   104. — Dilatation  of  the  ascending  aorta,   due  to  syphilitic  aortitis.     A 
well-marked  case. 


Esophagus. — In  an  occasional  case  of  cardiospasm  the  esophagus 
may  be  dilated  to  such  an  extent  as  to  appear  as  a  long,  smooth 
shadow  c.iu"ving  outward  into  the  right  lung  fields.  It  may  be 
recognized  by  the  fact  that  it  continues  upward  above  the  clavicles 
and  by  the  use  of  a  bariimi  meal.  It  must  not  be  forgotten  that 
diverticulum  of  the  esophagus  may  simulate  mediastinal  tumor, 
capsulated  empyema  and  aneurysm. 


THE  HEART  AND  GREAT  VESSELS 


129 


Diaphragm. — Xormally  the  diaphragm  curves  smoothly  from  the 
pericardmm  downward  to  form  a  sharp  angle  with  the  plem-a. 
The  right  side  is  higher  than  the  left  (one  or  more  centimeters),  and 
in  some  cases  shows  several  small  curves  near  the  dome  due  to 
inequalities  in  the  liver  which  have  no  significance.  Fluoroscopically, 
it  should  move  freely  and  equally  on  the  two  sides  both  on  quiet 
and  deep  respiration. 


1 
67 

8,5 

10.3 

^5 

^^                        U  : 

Fig.  105. — Aneur^-sm  of  the  ascending  aorta. 


Changes  in  Outline. — ^Marked  irregularities  on  the  surface  of  the 
liver  ma}'  be  transmitted  through  it.  Bands  of  adhesions  to  the 
pleura  or  the  chest  wall  may  elevate  small  stringy  or  triangular 
areas. 

Changes  in  Mobility. — Slight  limitation  of  motion  may  be  observed 
when  the  patient  is  breathing  quietly,  which  disappears  completely 
with  deep  respiration.  Bilateral  limitation  of  motion  may  be  due 
9 


130 


THE  CHEST 


to  emphysema,  ptosis,  ascites,  peritonitis,  pleuritis  at  the  base  of 
both  lungs,  or  fibrosis  from  an  old  inflammatory  process.  When 
unilateral,  we  must  look  above  the  diaphragm  for  tuberculosis  or 
disease  of  the  pleura  on  that  side  or  below  it  for  an  inflaimiiatory 
process  such  as  a  diseased  appendix  or  gall-bladder,  subdiaphrag- 
matic or  liver  abscess.  Paradoxical  excursion  of  the  diaphragm  is 
seen  in  paralysis  of  the  phrenic  nerve  and  diaphragmatic  hernia. 
The  afi'ected  side  ris'es  during  inspiration  and  falls  during  expiration. 


Fig.  106. — An  abscess  of  the  liver  which  contained  gas  as  well  as  pus. 
was  taken  with  the  patient  in  the  upright  position-. 


The  plate 


Changes  in  Position. — It  is  low  in  ptosis  and  emph^^sema.  It  is 
high  in  adiposity,  ascites  and  subphrenic  abscess,  eventration  and 
hernia  of  the  diaphragm.  Eventration  and  hernia  are  both  more 
common  on  the  left  side.  In  eventration,  although  considerably 
elevated,  its  contour  is  preserved  and  movement  is  normal  in  direc- 
tion though  limited.  In  hernia  its  outline  is  obscured  and  its  move- 
ment paradoxical.  In  both  cases  the  barium  meal  will  demonstrate 
the  position  of  the  abdominal  viscera. 

Pleural  Effusions. — Pleural  effusions  obliterate  the  costodiaphrag- 
matic  angle  if  small  or  the  entire  diaphragmatic  shadow  if  they  are 


LUNG  FIELDS  131 

extensive.     It  is  worth  noting  that  in  rare  cases  fluid  may  be 
obtained  from  a  chest  that  is  roentgenologically  negative. 

Subdiaphragmatic  Abscess. — Subdiaphragmatic  abscess  causes 
marked  upward  displacement  of  the  shadow  of  the  diaphragm. 
The  top  is  usually  considerably  flattened  and  excursion  is  abolished. 
Encapsulated  fluid  above  the  diaphragm  may  strongly  resemble 
subdiaphragmatic  eftusion. 


Fig.  107. — Encapsulated  empyema.     The  process  is  between  the  lower  and 

middle  lobes. 

LUNG  FIELDS. 

Technic. — Lung  examination  should  include  both  fluoroscopy  and 
plates,  preferably  in  the  erect  position.  AVhen  the  patients  can 
hold  their  breath,  stereoscopic  plates  have  great  value  but  they  are 
not  necessities.  In  certain  conditions  examination  in  the  prone, 
oblique  and  lateral  positions  should  be  made.  It  is  usually  advis- 
able to  take  both  anteroposterior  and  postero-anterior  plates.    The 


132  THE  CHEST 

number  and  position  of  the  plates  to  be  taken  may  be  determined 
at  the  fluoroscopic  examination. 

Normal  Lung. — The  normal  lung  markings  consist  of  small  areas 
of  density  at  the  hilus  which  often  show  calcified  spots,  and  strands 
of  density  corresponding  to  the  bronchial  tree  spreading  out  through 
the  lung  fields  for  a  considerable  distance  but  never  quite  reaching 
the  plem'a.  The  descending  bronchi  on  both  sides  are  usually  more 
dense  than  those  above.  The  fields  are  of  equal  density  on  the  two 
sides.  They  are  slightly  obscm-ed  by  the  pectoral  muscles  and  in 
the  breasts  in  postero-anterior  views  and  there  is  usually  some  slight 
haziness  in  the  left  base  in  the  region  of  the  apex  of  the  heart. 

Pathological  Changes. — Diffuse  increase  in  density  on  one  or  both 
sides  is  found  in  thickened  pleura,  fluid,  consolidation  or  bronchial 
stenosis.  A  general  increase  in  radiability  is  due  to  emphysema. 
Local  areas  of  increased  radiability  may  be  due  to  pneumothorax 
or  cavity  formation.  Localized  areas  of  increased  density  are  most 
likely  to  be  abscess,  localized  pneumonia  about  a  foreign  body  or 
malignancy. 

Licrease  in  size  of  the  root  shadows  may  be  due  to  infection  or 
tumor. 

Increased  thickening  of  the  bronchial  markings  means  infection 
or  fibrosis.  Fine  mottling  along  the  bronchi  is  usually  due  to  the 
early  manifestations  of  tuberculosis.  Fine  mottling  in  the  lung 
tissue  usually  means  tuberculosis,  fibrosis  or  malignancy.  Coarse 
mottling  in  the  lung  tissue  is  due  to  bronchiectasis,  tuberculosis 
or  metastatic  malignancy.  Displacement  of  mediastinal  contents 
occurs  with  eftusion,  adhesions,  fibrosis  and  tumors.  Li  the  case 
of  tumors,  displacement  is  often  toward  the  side  affected  by  the 
growth. 

Pleura. — I'hickening  occm's  as  a  result  of  inflammation  and  may 
obscm-e  all  of  one  or  both  chests  or  may  be  limited  to  the  base  or 
apex.  The  shadow  is  fairly  dense  although  the  ribs  can  usually  be 
seen  through  it.  A  thin,  ciuved,  white  line,  convex  upward,  extend- 
ing across  the  chest  is  occasionally  seen  as  the  end-result  of  an 
interlobar  pleurisy.  Adhesions  appear  as  strands  of  increased 
density.    At  the  apex  theii"  appearance  may  suggest  cavities. 

Pleural  Exudate. — An  effusion  or  empyema  usually  gives  a  shadow 
of  extreme  density  located  at  the  base,  obscuring  the  ribs  and 
diaphragm  with  a  superior  margin  which  curves  upward  toward 
the  chest  wall  in  the  axilla,  unless  pneumothorax  is  present,  when  it 
will^show  a  fluid  le\'el  which  changes  as  the  patient's  position  is 


LUNG  FIELDS 


133 


shifted.  In  the  prone  position  the  shadow  is  uniform  throughout 
the  chest  and  often  resembles  that  of  thickened  pleura.  If  an  effu- 
sion is  extensive,  there  is  usually  displacement  of  the  heart  and  great 
vessels.  The  apex  is  usually  clear.  In  young  children  fluid  may 
appear  as  a  dense  area  along  the  periphery  of  the  lung  field. 

Encapsulated  fluid  gives  a  dense,  sharply  defined  shadow  in  con- 
tact with  the  pleura.  It  is  most  common  at  the  base,  along  the 
axillary  border  or  between  lobes.  When  the  collection  is  between 
lung  and  diaphragm  it  may  simulate  subdiaphragmatic  abscess. 


Fig.  108. — Pneumothorax,  with  complete  collapse  of  the  left  lung. 


Pneumothorax. — Pneumothorax  is  characterized  by  the  presence 
in  the  periphery  of  the  lung  field  of  an  area  of  greatly  increased 
radiability  from  which  the  lung  markings  are  absent.  Its  borders 
are  sharph'  defined  and  consist  of  the  walls  of  the  chest  cavity  and 
the  margins  of  the  compressed  lung.  When  the  pneumothorax  is 
complete  and  there  are  no  adhesions,  the  lung  collapses  to  a  lobu- 
lated  mass  at  the  hilus  in  which  can  usually  be  seen  the  suggestion 


Fig. 


109. — Hydropneumothorax.     This  plate  was  taken  with  the  patient  upright. 
The  fluid  level  is  well  shown  at  about  the  middle  of  the  left  chest. 


Fig.  110. — Old  empyema,  with  calcification  in  the  right  pleura. 


LUNG  FIELDS 


135 


of  lung  marking.  In  the  presence  of  pleural  adhesions  where  the 
collapse  is  incomplete,  the  shadow  of  the  pnemnothorax  may  be 
divided  by  bands  which  give  it  a  sacculated  appearance  and  pneumo- 
thorax and  lung  tissue  may  overlap  each  other.  A  small  localized 
pneumothorax  may  be  difficult  to  detect  unless  it  is  seen  in  profile; 
otherwise  it  appears  as  an  area  of  somewhat  increased  radiability 
overlaid  by  normal  lung  markings.  This  should  not  be  confused 
with  large  cavities  which  occur  in  the  substance  of  the  lung  and  may 
or  may  not  have  well-defined  borders. 

Calcifications  frequently  appear  in  the  pleura  in  a  form  of  ragged 
plaques  or  lines  which  occur  in  any  portion  of  it. 


Fig.  111. — Peribronchial  tuberculosis.     Advanced  tuberculosis  two  years  later. 


Tuberculosis. — ^The  primary  focus  in  tuberculosis  is  probably  in 
the  periphery  of  the  lung  but  it  is  not  always  evident.  However, 
w^e  see  an  increase  in  the  root  shadows  as  a  result  of  glandular 
involvement  which,  particularly  in  children,  is  often  marked.  In 
the  acute  stage  their  outlines  are  blurred  and  indistinct.  If  healing 
occurs  the  shadows  gradually  diminish  in  size,  increase  in  density 
and  sharpness  of  outline,  and  subsequently  show  areas  of  calcification.,, 
As  the  infection  progresses,  the  next  change  is  general  thickening 


136 


THE  CHEST 


of  the  bronchial  markings  along  the  track  of  the  disease,  usually 
toward  one  or  both  tops.  When  this  has  occurred  the  patient  will 
usually  show  dullness  at  the  affected  area  clinically.  Because  of 
the  normal  thickening  toward  both  bases  the  stage  is  difficult  to 
recognize  when  the  extension  is  downward  but  it  is  much  less  com- 
mon in  this  situation.  Plates  of  most  adult  lungs  show  a  certain 
amount  of  thickening  of  the  bronchial  markings  as  a  result  of  pre- 
vious infections  and  have  no  particular  significance.    When  due  to 


Fig.  112. — Tuberculosis  at  both  apices. 


tuberculosis,  the  changes  are  permanent.  The  demarcation  between 
the  normal  and  the  pathological  is  not  sharp  and  it  takes  consider- 
able experience  in  the  observation  of  plates,  combined  with  all  that 
can  be  found  by  clinical  methods,  to  establish  a  correct  diagnosis. 
If  the  process  continues,  small  bead-like  masses  appear  along 
the  course  of  the  thickened  bronchial  shadows  and  fan-shaped  areas 
of  filmy  density  may  be  seen  w4th  their  bases  on  the  pleura  and 
apices,  extending  inward  toward  the  thickened  markings.  These 
fan-shaped  areas  are  probably  the  earliest  evidence   of  definite 


LUNG  FIELDS 


137 


involvement  of  the  lung  parenchjTaa,  but  unfortunately  they  are 
not  commonly  seen  and  they  may  occur  m  other  infections. 

The  next  stage  is  the  appearance  through  the  diseased  area  of 
finely  stippled  grayish  spots,  apparently  independent  of  the  bronchial 
markings  now  extended  to  the  periphery  of  the  lung.  These  spots 
mean  definite  involvement  of  lung  tissue  and  at  this  time  rales  are 


Fig.  113. — Miliary  tuberculosis  of  the  lungs.     The  changes  are  most  marked 
in  the  upper  lobes. 


beginning  to  be  evident  upon  clinical  examination.  This  charac- 
teristic fine  mottling  is  the  only  sure  basis  for  a  roentgen  diagnosis 
of  active  tuberculosis.  It  is  seen  in  its  most  typical  form  in  the 
cases  of  miliary  tuberculosis. 

With  the  further  progress  of  the  disease  there  occurs  an  enlarge- 
ment and  effusion  of  these  spots  and  their  extension  to  new  areas, 
resulting  in  coarse  mottling  and  finally  evidence  of  cavity  formation. 


138 


THE  CHEST 


Areas  of  healing  may  occur  at  any  stage,  or  progress  and  healing 
may  be  simultaneous  so  that  it  may  be  impossible  to  decide  from 
roentgen  evidence  alone  whether  a  case  is  active  or  quiescent.  In 
general,  active  lesions  are  dim,  gray  and  blurred;  healed  ones  are 
more  dense  and  sharply  outlined. 

The  only  condition  which  must  be  differentiated  from  extensive 
tuberculosis  is  that  seen  in  pneumonoconiosis,  where  the  fibrous 
changes  and  symmetrical  portions  of  both  lungs  cast  a  cotton-like 


Fig.  114. — Lobar  pneumonia.    The  process  is  in  the  lower  part  of  the  right  upper  lobe. 


shadow  very  similar  to  that  of  fibroid  tuberculosis.  However,  the 
apices  are  usually  not  involved  and  the  patient  will  give  a  history 
of  having  worked  underground  or  in  a  dusty  occupation  and  his 
physical  signs  are  not  those  of  a  tuberculous  process  of  similar  extent. 
Miliary  tuherculosis  presents  a  characteristic,  fine,  hazy  mottling 
scattered  throughout  the  lung  fields  which  must  be  differentiated 
from  metastatic  malignancy  and  from  pneumonoconiosis.  Meta- 
stases in  rare  cases  appear  as  definite  small  discrete  areas  of  increased 


LUNG  FIELDS 


139 


density  scattered  throughout  both  hmgs,  but  the  spots,  while  approx- 
imating those  of  mihary  tuberculosis  in  size,  are  more  dense  and 
more  sharply  outlined.  From  pneumonoconiosis  it  may  be  differ- 
entiated by  the  fact  that  it  is  a  more  diffuse  process  involving  all 
portions  of  the  lung,  whereas  pneumonoconiosis  typically  in^'olves 
symmetrical  areas  and  spares  the  apices.  The  mottling  in  the  latter 
is  much  finer  and  the  dense  spots  are  smaller  than  those  seen  in 
tuberculosis. 


Fig.  115. 


-Pleurisy,  with  effusion  at  the  left  base.    Note  the  position  of  the  .shadow  in 
the  axillary  border  and  the  displacement  of  the  heart  to  the  left. 


Lobar  Pneumonia. — Lobar  pneumonia  is  characterized  by  areas  of 
increased  uniform  density  which  are  sharply  defined  and,  when  fully 
developed,  usually  occupy  the  position  of  a  lobe.  In  the  early 
stages  the  shadow,  while  uniform,  is  less  dense  and  may  be  triangular 
in  shape  with  the  base  on  the  pleura  and  the  apex  toward  the  hilus. 
The  lung  markings  distributed  to  this  area  are  thickened  and  the 


140 


THE  CHEST 


hilus  glands  are  enlarged.  It  has  been  observed  in  children  that 
dulhiess  and  changed  breath  and  A'oice  sounds  are  not  ordinarily 
perceptible  until  the  shadow  reaches  the  hilus. 

The  character  of  the  shadow  changes  with  the  progress  of  the 
disease  and  as  resolution  appears  it  becomes  distinctly  mottled. 
After  the  shadow  itself  has  disappeared,  thickened  bronchial  mark- 
ings or  large  glands  may  persist  for  a  considerable  time.  It  must  be 
differentiated  from  fluid  where  the  shadow  is  more  dense,  does  not 
conform  to  lobar  outlines,  and  displaces  the  heart  and  vessels. 


Fig.  116. — Bronchopneumonia  follo-^v-ing  operation  upon  the  nose.     The  patient  died 
two  days  after  this  plate  was  taken  and  the  findings  were  confirmed  at  autopsy. 


Bronchopneumonia. — Bronchopneumonia  occurs  more  frequently 
than  is  generally  thought.  Chving  to  the  absence  of  physical  signs, 
the  diagnosis  may  depend  largely  upon  the  roentgen  examination  and 
the  history.  The  appearance  is  that  of  single  or  multiple  areas  of 
increased  density  with  hazy  outlines,  usually  situated  near  the  course 
of  the  larger  bronchi.  The  differentiation  from  abscess,  bronchiec- 
tasis and  malignancy  depends  largely  upon  the  clinical  history. 


LUNG  FIELDS 


141 


Unresolved  Pneumonia. — Unresolved  pneumonia  gives  a  shadow 
resembling  that  of  pneumonia.  It  must  be  distinguished  from  an 
interlobar  empyema,  tuberculous  pneumonia,  or  bronchial  stenosis 
largely  by  the  clinical  and  laboratory  findings.  It  has  been  noted 
that  unresolved  pneumonias  may  disappear  after  mild  roentgen 
radiation. 

Bronchitis. — Bronchitis,  when  acute,  gives  no  characteristic  pic- 
ture. The  chronic  inflammations  appear  as  an  increase  in  the  size 
and  density  of  bronchial  m.arkings  and  glands. 


Fig.  117. — Lung  abscess.     The  cavity  of  the  abscess  can  be  seen  as  an  area  of 
diminished  density  in  the  center  of  the  dull  area  in  the  right  chest. 


Lung  Abscess. — Lung  abscess  usually  follows  influenza  or  the 
inspiration  of  infected  material  at  operation  or  of  foreign  bodies. 
Clinically  it  is  a  disease  of  symptoms  rather  than  physical  signs,  so 
that  the  roentgen  examination  is  of  the  greatest  help  in  indicating 
the  site  and  extent  of  the  process  from  its  early  stages.  The  lesions 
are  usually  single,  although  they  may  be  multiple  and  may  occur 
in  either  lung  field,  showing,  however,  a  decided  preference  for  the 
bases,  particularly  the  right.  They  assume  the  form  of  irregular 
areas  of  increased  density  which  are  most  marked  at  the  center, 


142  THE  CHEST 

fading  out  toward  the  periphery.  Cavity  formation  is  extremely 
common  in  the  areas  of  infiltration.  When  filled  with  fluid  they  are 
indistinguishable  from  the  general  shadow  about  them  but  the 
larger  ones  become  very  evident  w^hen  filled  with  air,  particularly 
if  they  certain  sufficient  fluid  to  cause  a  fluid  level.  They  are  seen 
as  round  areas  of  greatly  diminished  density  and,  if  a  fluid  level  is 
present,  its  surface  shifts  according  to  the  position  of  the  patient. 
Small  cavities  may  t>e  entirely  overlooked.  The  bronchial  markings 
distributed  to  the  areas  involved  are  enlarged  and  coarse  and  the 
hilus  shadows  are  increased  in  size.  Abscesses  may  persist  for  a 
long  time  as  areas  of  thickening  or  heal  spontaneously  without  leav- 
ing a  trace  of  their  presence  on  the  roentgenogram.  Their  localiza- 
tion is  often  disappointing  to  the  surgeon  because  of  the  zone  of 
pnemnonic  infiltration  about  them  which  magnifies  the  area  of 
involvement.  iVbscesses  may  be  confused  with  tuberculosis,  broncho- 
pneumonia and  bronchiectasis.  The  similarity  to  tuberculosis 
lies  in  the  occurrence  of  cavities.  In  tuberculosis  there  is  other 
roentgen  evidence  of  the  disease  in  the  form  of  characteristic  mot- 
tling elsewhere  in  the  lungs  and  especially  at  the  apices.  Abscess 
is  more  common  at  the  bases  and  the  apices  are  clear.  Broncho- 
pneumonia may  be  differentiated  by  the  fact  that  it  gives  a  shadow 
of  more  uniform  density  and  there  is  no  cavity  formation.  Bron- 
chiectasis is  usually  a  diffuse  process  and  the  bronchial  changes  are 
more  extensive.  However,  the  two  conditions  blend  into  each 
other  at  times.  .-^  - 

Bronchiectasis. — The  characteristic  picture  in  a  well-advanced 
case  is  an  extensive  thickening  of  the  lung  markings  along  the 
course  of  the  larger  bronchi  and  enlargement  of  the  hilus  glands 
with  the  presence  of  single  or  multiple  areas  of  increased  density 
in  the  lung  fields  near  the  bronchi,  which  may  show  considerable 
change  in  plates  taken  before  and  after  evacuation.  Cavities  can 
often  be  demonstrated.  In  the  early  stages  the  picture  is  much 
less  characteristic  and  depends  upon  the  demonstration  of  small 
ring-like  shadows  of  dilated  bronchi  which,  however,  are  usually 
obscured  by  the  infiltrated  lung  about  them. 

Foreign  Bodies. — Foreign  bodies  most  commonly  lodge  in  the  right 
bronchus  and  may  be  recognized  if  of  sufficient  density  to  cast  a 
shadow.  Their  presence  may  be  the  cause  of  an  area  of  increased 
density  due  to  a  localized  pneumonia  about  them,  to  abscess  forma- 
tion or  to  collapse  of  one  or  more  lobes  as  a  result  of  broncho- 
stenosis.    Examination  for  foreign  bodies  should  include  obserN'a- 


LUNG  FIELDS 


143 


tion  of  the  entire  respiratory  tract  from  different  angles,  a  lateral 
view  of  the  chest  is  often  very  helpful,  any  inspection  of  the  larynx 
and  the  neck  should  be  included. 


Fig.  118.- 


-Bronchiectasis.     The  process  is  fairly  well  localized  in  the  right  lower 
chest.     The  dilated  and  sacculated  bronchi  are  visible. 


Bronchostenosis. — Bronchostenosis  gives  a  uniform  dense  shadow 
throughout  the  area  supplied  by  the  affected  bronchus  and  the 
movements  of  the  diaphragm  are  limited  on  the  affected  side.  It 
occurs  as  a  result  of  inspired  foreign  bodies,  aneurysm,  tumors  or 
lues. 

Gangrene. — Gangrene  casts  an  extensive  shadow  which  may 
occupy  one  entire  lung  field.     Its  characteristic  features  are  the 


144 


THE  CHEST 


presence  of  large  irregular  areas  of  diminished  density  and  a  general 
coarse  mottling  of  the  lung.  The  heart  and  mediastinal  contents 
are  not  displaced.  This  appearance  may  be  simulated  by  a  lung 
which  has  recently  expanded  after  a  prolonged  pneumothorax. 

Primary  Malignancy. — Primary  malignancy  of  the  lung  is  rare. 
It  is  practically  always  unilateral.  The  usual  growth  is  a  carcinoma 
which  occurs  in  two  t\TDes,  nodular  and  infiltrating.     The  former 


Fig.  119. — Malignant  disease  of  the  lungs  in  a  child.    The  entire  left  chest,  including 
the  apex,  is  dull.     The  trachea,  as  well  as  the  heart,  is  displaced  to  the  right. 


consists  of  dense,  rounded  masses,  sharply  marked  off  from  the  lung 
tissue,  occurring  near  the  hilus.  Ragged,  irregular  cavity  formation 
in  the  tumor  mass  sometimes  occurs.  In  the  infiltrating  tj^pe,  the 
tumor  arises  from  a  bronchus  and  infiltrates  the  lung  along  the 
bronchial  ramifications.  The  edges  of  the  growth  are  apt  to  be 
smooth  except  along  the  advancing  margin  tow^ard  the  periphery 
of  the  lung.  These  growths  may  also  extend  toward  the  root  and 
form  large  masses  at  the  hilus.    Collapse  of  the  lung  with  displace- 


LUNG  FIELDS  145 

ment  of  the  heart  to  the  affected  side  may  take  place.     Fluid  in 
the  pleural  space  occurs  early. 

Metastatic  Malignancy. — ^Metastatic  malignancy  appears  in  three 
forms.  In  the  first  there  is  progressive  enlargement  of  the  hilus 
shadows  which  is  unrecognizable  in  the  early  stages  and  unmis- 
takable in  the  later  ones  when  large  masses  have  developed  at  the 
lung  roots  and  usually  an  effusion  at  one  or  both  bases.    A  second 


Fig.  120. — Malignant  metastasis  in  the  lungs  from  carcinoma  of  the  stomach. 

and  perhaps  more  common  form  is  that  in  .which  the  growths  take 
the  form  of  multiple,  thin,  rounded  plaques  of  variable  size,  with 
sharp  margins  which  are  scattered  throughout  the  lung  fields. 
In  the  third  type  there  is  a  fine  mottling  throughout  the  lung  fields 
which  may  suggest  miliary  tuberculosis,  but  the  small  areas  of 
increased  density  are  a  little  larger,  more  dense,  and  more  sharply 
outlined  than  those  of  tuberculosis.  Two  or  more  of  these  forms 
may  occur  together. 
10 


Fig.  121. — Metastasis.     Malignant  disease  of  the  lung  and  pleura. 


Fig.  122. — Metastatic  carcinoma  involving  the  bones,  lungs  and  pleura. 


LUNG  FIELDS 


147 


Syphilis. — There  is  considerable  discussion  on  the  subject  of  lung 
sj'philis  but  undoubted  cases  have  been  reported.  It  is  evidenced 
in  three  types.  In  the  first,  there  is  a  general  thickening  of  all  of  the 
bronchial  markings,  particularly  marked  toward  the  hilus,  giving 
a  fan-shaped  shadow  radiating  out  into  the  lung  fields.  In  the 
second,  supposed  to  be  gummata,  there  are  one  or  more  dense  dis- 
crete masses  to  be  made  out  in  the  region  of  the  hilus.    The  third 


Fig.  123. — There  is  an  extensive  chronic  inflammatory  process  involving  both  lungs, 
the  left  much  more  than  the  right.     Clinically  it  was  thought  to  be  syphilitic. 

form  occurs  as  a  diffuse  shadow  obscuring  one  entire  side  of  the 
chest  which  may  clear  wholly  or  in  part  under  appropriate  treat- 
ment. One  characteristic  feature  of  these  patients  is  that  the  lesions 
are  much  more  extensive  than  their  condition  would  lead  one  to 
suspect, 

Echinococcus. — Echinococcus  occurs  as  dense,  circular,  sharply 
defined  areas  of  increased  density  within  the  lung  field.  They  may 
or  may  not  have  an  evident  cystic  wall  and  ordinarily  are  not  con- 


Fig.  124. — Echinococcus  cyst  at  the  base  of  the  right  lung 


Fig.  125. — Actinomycosis  of  the  hmgs.     In  this  case  the  changes  are  most  marked 
around  the  right  descending  bronchus  and  resemble  bronchiectasis. 


THE  HEART  AND  GREAT  VESSELS 


149 


nected  with  the  mediastinum.  If  rupture  of  the  cyst  has  occurred, 
the  picture  will  simulate  that  of  lung  abscess. 

Actinomycosis. — ^Actinomycosis  usually  occurs  in  the  form  of  a 
lung  abscess  and  diagnosis  is  made  bacteriologically. 

Pneumonoconiosis  ( Anthracosis,  Chalicosis) . — Pneumonoconiosis 
may  occur  as  a  diffuse,  fine  mottling  s^Tnmetrically  distributed 
throughout  both  lungs.  The  apices  may  be  involved  although  such 
is  not  usually  the  case.      The  picture  is  very  suggestive  of  miliary 


Fig.  126. — Potterj-  workers'  lungs.     Pneumonoconiosis. 

tuberculosis.  However,  there  will  usually  be  a  long  history  of 
occupational  exposure  to  dust  and  there  is  little  or  no  clinical  evi- 
dence of  a  process  as  extensive  as  the  roentgenogram  would  indicate, 
the  mottling  is  more  dense  and  the  areas  are  smaller,  more  .sharply 
defined,  and  more  uniform  in  size  than  tho.se  of  tuberculosis. 

Another  form  of  this  disease  is  seen  frequently  in  gold  mine  and 
pottery  workers,  and  appears  as  a  diffuse  process  involving  bothjungs, 
particularly  the  upper  lobes,  and  from  the  plates  alone  cannot  be 
distinguished  from  fibroid  phthisis. 


150  THE  CHEST 


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Baetjer,  W.  A.:    Pulmonary  tuberculosis,  Internat.  Clin.,  1916,  xxvi,  iii,  p.  124. 

Wood,  N.  K.:   Syphilis  of  the  lungs,  British  Med.  Surg.  Jour.,  1916,  clxxv,  p.  677. 

Simon,  C.  E.:   Yeast  infection  of  the  lungs.  Am.  Jour.  Med.  Sc,  1917,  cliii,  p.  231. 

Scott,  E.,  and  Forman,  J.:  Primary  carcinoma  of  the  lungs,  New  York  Med. 
Rec,  1916,  xc,  p.  452. 

Hulst,  H.:  Roentgenological  diagnosis  of  tuberculosis  of  the  lungs.  Am.  Jour. 
Roent.,  1916,  iii,  p.  465. 

Dietlen:    Munchen.  med.  Wchnschr.,  1913,  clx,  p.  1763. 

Vaquez  and  Bordet:  Le  Coeur  et  I'aorte:  Etudes  de  Radiologic  Clin. 

Jaugeas:   Precis  de  Radiolog.  Tech.  et  Clin. 

Bietlen,  H.:    Deutsch.  Arch.  f.  klin.  Med.,  1906-1907,  Ixxxviii,  p.  55. 

Holzknecht:   Fortschritte  a.  d.  Geb.  d.  Roentgenstr.  Erganzungheft,  6,  p.  117. 

Guttman:    Ztschr.  klin.  Med.,  1906,  Iviii,  p.  353. 

Groedel,  F.  M.:  Die  Roentgendiagnostic  der  Herz-  und  Gefasserkrankungen, 
Berlin,  1912,  pp.  14-16. 

De  la  Camp:  Verhand.  f.  d.  Cong.  f.  miinchen.  Med.,  1904,  xxi,  p.  208.  Con- 
clusions of  Resume. 

A.  Kohler:    Teleroentgenography,  Deutsch.  med.  Wchnschr.,  1908,  xxxiv,  p.  186. 

Dietlen:  Orthodiagraphie  und  Teleroentgenographie  als  Methoden  der  Herz- 
messung,  Munchen.  med.  Wchnschr.,  1913,  Ix,  1763-1766. 

Albers,  Schonberg:   Die  Roentgen technik. 


CHAPTER   VIII. 

GASTRO-INTESTINAL  TRACT. 

Technic. — Both  fluoroscopy  and  plates  are  necessary  for  adequate 
examination  of  the  gastro-intestinal  tract.  Fluoroscopy  gives  infor- 
mation in  regard  to  mobility  and  function  which  cannot  be  secured 
from  plates,  and  plates  give  details  of  structure  which  may  be  over- 
looked on  the  screen  so  that  the  methods  are  complementary.  The 
value  of  fluoroscopy  depends  upon  the  experience  of  the  man  who 
is  doing  it,  and  when  fluoroscopy  is  referred  to  hereafter  it  is  under- 
stood to  mean  that  of  a  thoroughly  trained  operator.  With  a  good 
screen  examination,  six  or  eight  plates  should  be  sufficient  in 
most  cases.  The  secret  of  success  in  this  work  is  thoroughness, 
which  is  more  essential  here  than  in  any  field  of  roentgenology. 
Examinations  must  be  frequently  repeated  and  the  patient  ade- 
quately studied  before  an  opinion  is  rendered.  As  far  as  possible, 
a  routine  technic  should  be  employed  throughout.  There  should 
be  no  preliminary  catharsis.  A  standard  meal  of  uniform  amount 
and  composition  should  be  administered  to  the  patient  at  about 
his  customary  meal  time.  The  barium  may  be  given  in  8  ounces 
of  buttermilk  or  potato  starch  gruel  and  the  original  meal  maj'  be 
followed  along  its  course  or  the  double  meal  may  be  employed. 
In  the  latter  method  the  patient  should  receive  his  barium  in  a 
carbohydrate  breakfast  of  at  least  16  ounces,  reporting  for  exami- 
nation six  hours  later,  when  the  position  of  the  morning  meal  is 
observed  and  a  second  standard  meal  administered.  This  latter 
method  is  the  one  most  in  use  in  the  larger  clinics,  perhaps  because 
of  the  saving  in  time  it  effects.  It  will  be  found  thoroughly  prac- 
ticable in  most  cases.  The  patient  should  be  examined  in  the  stand- 
ing, prone,  supine  and  right  lateral  positions,  A  brief  knowledge 
of  the  clinical  history  is  essential,  and  whether  it  be  secured  before 
or  after  the  roentgen  examination  is  a  matter  of  personal  preference, 
but  the  roentgen  findings  and  the  history  must  be  correlated  at  some 
time  before  a  diagnosis  is  made.  The  accuracy  of  the  method  will 
vary  with  the  personality  and  training  of  the  observer.    The  diag- 


152 


GASTRO-INTESTINAL  TRACT 


noses  of  the  a^'erage  man  will  be  about  75  per  cent,  correct.  With 
the  best  roentgenologists  under  the  most  favorable  circumstances, 
roentgen  findings  in  this  field  should  be  85  to  90  per  cent,  correct. 


ESOPHAGUS. 


The  esophagus  is  grossly  outlined  with  the  ordinary  barium  meal. 
For  more  prolonged  observation,  particularly  in  cases  of  suspected 
new  growth,  a  mixture  of  barium  sulphate  and  mucilage  of  acacia  or 
gelatin  is  of  great  value.    In  the  right  oblique  diameter  the  normal 


Fig.  127. — Cardiospasm. 


Note  the  esophagus  to  the  right  and  the  round,  smooth 
borders  of  the  barium  shadow. 


esophagus  is  easily  seen  throughout  its  course.  It  presents  a  slight 
indentation  at  the  level  of  the  arch  of  the  aorta  and  curves  forward 
behind  the  heart  to  enter  the  stomach.  It  is  smooth  in  outline  and 
the  opaque  mass  passes  readily  through  it  with  a  momentary  pause 
at  the  arch  and  a  longer  delay  at  the  cardia. 


ESOPHAGUS  153 

Pathological  Esophagus. — The  esophagus  may  be  greatly  dilated 
in  cardiospasm  or  benign  stricture.  In  the  former,  a  glass  of  hot 
water  may  relax  the  spasm  and  allow  part  or  all  of  the  meal  to  enter 
the  stomach.  There  is  no  discoverable  irregularity  in  outline  and 
the  shadow  ends  at  the  cardia  in  a  smooth,  funnel-shaped  mass. 
Dilatation  of  the  esophagus  occurring  as  a  result  of  cardiospasm  may 


Fig.  128. — Dilated  gas-filled  esophagus.     There  is  a  small  amount  of  barium  in  the 
lower  part.     Plate  was  taken  with  the  patient  upright. 


be  so  great  that  the  margins  of  the  esophagus  overlap  the  lung  field 
on  the  right  side.  In  these  cases  there  may  be  a  delay  of  the  meal 
above  the  cardia  for  hours  or  days.  Malignant  tumors  of  the  cardia 
of  sufficient  extent  to  cause  obstruction  can,  as  a  rule,  be  recognized 
by  irregularities  in  outline  of  the  barium  mass  in  the  lower  esophagus 
or  stomach. 


154 


G ASTRO-INTESTINAL  TRACT 


Changes  in  Position. — The  esophagus  may  be  displaced  by  medias- 
tinal tumors,  aneurysms,  effusion,  fibrosis  or  diseases  of  the  spine. 


Fig.   129. — Spasm  of  the  middle  third  of  the  esophagus  suggesting  malignant 

disease. 


Outline. — Irregularities  in  outline  are  most  commonly  due  to 
carcinoma  which  produces  a  persistent  defect  that  is  annular  and 
ragged  or  mottled.  It  is  most  commonly  found  in  the  lower  half  of 
the  esophagus.  Scar  tissue  within  the  esophagus,  ulceration  or  the 
ingestion  of  corrosives  results  in  multiple  constrictions  through  its 


Fig.  130. — Diverticulum  of  the  esophagus. 


Fig.  131. — Malignant  disease  of  the  esophagus  at  the  middle  third. 


156 


GASTRO-INTESTINAL  TRACT 


course.     The  contraction  of   extra-esophageal  fibrous  tissue  may 
result  in  constriction  or  sacculation. 

Diverticula. — Diverticula  may  be  found  anj-wliere  in  the  course 
of  the  esophagus,  most  commonly  the  upper  and  lower  ends.  They 
appear  as  rounded  pouches  which  overflow  into  the  esophagus 
through  an  opening  at  one  side.  It  may  be  necessary  to  view  the 
patient  from  several  angles  to  bring  this  opening  into  profile.  They 
remain  partially  filled  after  the  remainder  of  the  meal  has  passed  on. 
The  liquid  meal  is  to  be  preferred,  as  solid  masses  may  not  enter 
the  pocket.  In  rare  cases  the  meal  may  be  seen  to  enter  a  descending 
bronchus  as  a  result  of  broncho-esophageal  fistula,  usually  due  to 


carcnioma. 


STOMACH. 


In  the  standing  position  the  normal  stomach  hangs  more  or  less 
centrallv  in  the  abdomen  with  the  lesser  curvature  above  the  level 


Fig.  132. — Normal  stomach. 


of  the  crests  of  the  ilia.    The  greater  curvature  lies  at  a  variable 
distance  below  the  lesser.    The  form  and  position  of  the  stomach 


STOMACH 


157 


are  determined  by  the  architecture  of  the  individual,  the  tone  of 
the  gastric  wall,  the  tension  of  the  abdominal  muscles,  the  pressure 
of  neighboring  organs  and  the  amount  of  the  meal.  Thin  individuals 
with  a  narrow  costal  arch  have  long  central  stomachs  which  hang 
low  in  the  pelvis.  In  broad,  fat  individuals  with  a  wide  costal  arch 
and  in  those  of  strong  muscular  development  the  stomach  is  high 


Fig.  133. — Hyperperistalsis  in  an  othenvise  normal  stomach. 


ttnd  transverse.  In  asthenic  states  it  is  low  and,  because  of  the  lack 
of  tone,  the  meal  settles  in  the  lower  pole,  allowing  the  walls  of  the 
cardia  to  collapse.  In  the  prone  position  the  stomach  swings  up 
under  the  liver,  h'ing  more  transversely.  When  empty,  its  walls 
are  in  apposition  except  at  the  cardia  which  is  dilated  by  the 
gas  bubble.  As  the  stomach  fills,  the  meal  collects  in  a  funnel- 
shaped  shadow  below  the  gas  bubble  and  gradually  fills  out  the 


158 


G ASTRO-INTESTINAL  TRA CT 


body  and  antrum.    In  atonic  stomachs  the  meal  passes  rapidly  to 
the  lower  pole  which  enlarges  out  of  proportion  to  the  body. 

The  outline  is  smooth  except  for  indentations  due  to  peristalsis, 
and  a  variable  amount  of  irregularity  on  the  greater  curvature  due 
to  pressure  from  the  colon  and  spleen.  Small  transient  indentations 
occur  on  the  margins  of  the  antrum  near  the  pylorus.  They  are 
most  common  on  the  lesser  curvature  and  are  without  significance. 


Fig.  134. — Normal  stomach  deformed  by  pressure.     Plate  taken  \Yith  patient  prone. 


Normal  peristalsis  begins  at  about  the  middle  of  the  lesser  curva- 
ture with  a  shallow  depression  corresponding  to  it  on  the  greater 
curvature.  The  wa\'es  tra^'el  toward  the  pylorus  without  inter- 
ruption. They  become  progressively  deeper  as  they  pass  forward 
and  may  bisect  the  barium  mass  at  the  upper  limits  of  the  antrum. 
If  the  pylorus  opens,  the  antrum  then  contracts  as  a  whole,  forcing 
its  contents  into  the  duodenum.     If  not,  the  waves  move  on  to 


STOMACH 


159 


the  pylorus.  Peristaltic  waves  occur  at  intervals  of  about  twenty 
seconds,  varying  with  the  patient  and  the  meal  used.  Ordi- 
narily no  more  than  two  or  three  waves  are  visible  on  a  stomach 
at  the  same  time.  They  are  increased  in  number  and  depth  in  the 
prone  position  and  may  be  strongly  affected  by  mental  states,  being 
increased  by  rage  or  inhibited  by  fear  or  nausea. 


Fig.  1.3.5. — Tracing  of  normal  stomach. 


Pathological  Stomach. — The  stomach  is  increased  in  size  when 
dilatation  has  occurred  as  a  result  of  pyloric  obstruction  or  in  con- 
ditions where  there  is  a  general  loss  of  muscle  tone.  It  is  diminished 
in  size  (1)  as  a  result  of  increased  tone  from  strong  muscular  develop- 
ment or  as  a  reflex  from  disease  of  the  duodenum,  gall-bladder  or 
appendix,  and  (2)  as  a  result  of  infiltration  of  the  wall  as  seen  in 
ulcer,  carcinoma,  adhesions,  s^^hilis  and  linitis  plastica. 


160 


GASTRO-INTESTINAL  TRACT 


Changes  in  Position. — The  stomach  is  displaced  upward  and  to 
the  right  where  there  are  adhesions  to  the  liver  as  a  result  of  gall- 
bladder disease  or  from  the  presence  of  a  large  accumulation  of  gas 
in  the  splenic  flexure  or  tumors  in  the  left  upper  quadrant.  In  some 
cases  of  appendiceal  disease  or  adhesions  the  lower  pole  is  swung 
o\-er  toward  the  right  iliac  fossa.  It  may  be  displaced  and  rotated 
upward  on  its  long  axis  in  case  of  adhesions  to  the  anterior  abdominal 
wall.  General  gaseous  distention  of  the  intestine  or  fluid  in  the  peri- 
toneal cavity  crowds  the  stomach  upward  against  the  liver.    Displace- 


Pylonis 


Fig.  136. 


Jncisuixr. 


-Tracing  of  stomach,  showing  a  small  ulcer  on  lesser  curvature  near  the 
pylorus.     There  is  no  visible  crater. 


ment  doAvnward  (ptosis)  is  of  no  importance  unless  accompanied  by  a 
six-hour  residue  or  definite  clinical  evidence  of  abnormal  function. 
It  may  be  shifted  downward  and  to  the  left  by  enlargement  of  the 
liver  or  tumors  in  the  right  upper  cpjadrant.  In  i)yloric  obstruction 
where  dilatation  has  occurred  the  stomach  shadow  often  appears 
farther  to  the  right  than  normal,  but  this  is  due  to  dilatation  of  the 
antrum  and  is  not  a  true  displacement  of  the  entire  stomach. 

Changes  in  Outline. — Changes  in  outline  occur  (1)  as  a  result  of 
spasm.    This  may  be  localized  as  seen  in  the  narrow  contractions 


STOMACH 


161 


near  the  pylorus  or  in  the  upper  portion  of  the  body  of  the  stomach 
where  the  greater  curvature  is  drawn  in  toward  the  lesser  over  a 
space  of  a  few  millimeters.  These  spasms  may  be  reflex  or  be  due 
to  the  irritation  of  a  small  ulcer  or  new  growth  at  that  level.  Spasm 
may  also  be  extensive,  obliterating  the  entire  antrum,  for  example. 
Here  again  it  may  be  entirely  reflex  or  be  due  to  an  associated  lesion 


Fig.   137. — Tracing  of  stomach,  showing  penetrating  ulcer  of  lesser  curvature. 

Patient  prone. 


of  the  stomach  wall,  which  is  often  a  difficult  matter  to  decide. 
Functional  spasms  usually  are  transitory  so  that  repeated  observa- 
tions of  the  patient  will  frequently  settle  the  matter.  Antispas- 
modics, such  as  belladonna  or  papaverin,  may  be  emploj^ed,  but 
they  are  not  conclusive  because  of  the  fact  that  at  times  they  relax 
the  spasm  associated  with  a  lesion  of  the  wall  as  readily  as  those 
due  to  functional  causes;  so  that  the  question  of  the  presence  or 
11 


162 


GASTRO-INTESTINAL  TRACT 


absence  of  a  lesion  must  depend  upon  other  evidence  than  that  of 
spasm.  (2)  As  a  result  of  gastric  lesions.  Under  this  heading 
come  the  contracted,  rigid,  smooth  lesser  curvatures  with  absence 
of  peristalsis  seen  in  ulcer  and  carcinoma;  the  presence  of  the 
crater  of  a  penetrating  or  perforating  ulcer  projecting  from  the  gas- 
tric outline  on  the  lesser  curvature  or  posterior  wall;    marked 


Fig.  138. — Stomach  sho-wing  penetrating  ulcer  of  lesser  curvature.    Patient  standing. 


irregularities  of  carcinoma  which  vary  according  to  the  size,  shape 
and  position  of  the  tumor.  These  deformities  are  usually  either 
annular  or  due  to  the  presence  of  irregular  masses  invading  the 
barium  mixture,  leaving  ragged  holes  or  markings  suggesting  finger 
prints.  We  may  also  have  the  local  contractions  due  to  an  ulcer 
with  its  associated  spasm ;   or  the  extensive  defects  of  lues,  suggest- 


STOMACH 


163 


ing  ulcer  or  carcinoma.  Another  deformity  is  that  which  occurs 
as  the  result  of  contraction  of  scar  tissue  in  the  gastric  wall,  produc- 
ing a  so-called  hour-glass  stomach.  This  deformity  is  constant  in 
all  positions.  (3)  Defects  due  to  extragastric  causes  such  as  tumors 
or  pressure  as,  for  example,  the  gall-bladder  which  produces  a 
rounded  depression  in  the  region  of  the  pylorus,  or  pancreatic  tumors 
which  cause  irregularity  of  the  greater  or  lesser  curvature,  are  not 


Fig.  139. — Tracing  of  stomach,  showing  large  ulcer  on  lesser  curvature. 


constant  in  all  positions  of  the  patient.  An  enlarged  liver  may  cause 
defect  in  the  antrum  by  compressing  it  against  the  spine.  In  plates 
taken  in  the  prone  position  the  pressure  of  the  spine  against  the 
abdominal  wall  commonly  causes  a  break  in  the  barium  shadow 
overlying  it.  Perigastric  adhesions,  particularly  those  about  the 
pyloric  end  of  the  stomach,  may  produce  ragged  defects  suggesting 
carcinoma  but  as  a  rule  they  are  not  constant  in  all  positions. 
(4)  Any  solid  material  in  the  stomach,  such  as  food  masses,  foreign 


164 


GASTRO-IXTESTIXAL  TRACT 


bodies,  hair  balls,  and  the  like,  may  cause  defects  in  the  barium 
mass  resembling  malignant  disease.  However,  these  irregularities 
shift  with  changes  in  position  of  the  patient  and  there  is  no  inter- 
ference with  peristalsis.  Papillomata  produce  a  defect  similar  to 
that  seen  in  large  foreign  bodies,  but  there  is  little  displacement  of 


Fig.  140. — Tracing  of  stomach,  showing  large  saddle  ulcer. 


the  defect  with  change  in  position  of  the  patient,  peristalsis  is  not 
interfered  with,  and  they  are  constant  on  repeated  examinations. 

Changes  in  Peristalsis. — Increase  in  the  depth  or  speed  of  waves 
may  be  due  to  reflex  or  irritative  causes  or  compensatory  to  a 
diseased  pylorus.  In  the  early  stages  of  pyloric  obstruction  the 
waves  are  deep  and  vigorous.    They  may  bisect  the  stomach,  giving 


STOMACH  165 


it  the  appearance  of  a  row  of  balls.  The  waves  also  start  higher  and 
more  are  visible  at  the  same  time.  Peristaltic  waves  are  lost  in 
achylia,  in  the  stage  of  decompensation  of  pyloric  stenosis,  in  infil- 


FiG.  141. — Tracing  of  stomach,  showing  ulcer  at  fundus  and  large  ulcer  of  the  lesser 
curvature  invohing  the  pylorus. 

tration  of  the  gastric  wall,  and  in  nausea,  fear  or  faintness.  They 
are  irregular  where  they  encounter  areas  of  infiltration  in  the  gastric 
wall  or  strands  of  adhesions  and  possibly  in  some  functional  dis- 
turbances.   Peristalsis  is  reversed  in  carcinoma  and  tabes. 


Fig.  142. — Penetrating  ulcer  of  the  lesser  curvature  and  ulcer  of  the  duodenum. 


Fio.  14.3. — Large  saddle  ulcer  causing  hour-glass  stomach. 


STOMACH 


w: 


Incjsura 


Fig.  144. — Cancer  high  on  the  lesser  curvature.    Note  the  large  area  involved  and  the 
absence  of  a  definite  projection. 


Incisura.  Pijlomis 

Fig.  145. — Malignant  disease  of  the  lesser  curvature. 


168  GASTRO-INTESTINAL  TRACT 

Motility. — The  normal  stomach  empties  in  three  to  six  hours, 
depending  upon  the  amount  and  composition  of  the  meal,  the  tone 
of  the  stomach  and  its  functional  activity.  If  it  empties  in  less  than 
three  hours,  ach^^ia,  an  incompetent  pylorus,  duodenal  ulcer  or 
gall-bladder  disease  is  suggested.  If  there  is  a  definite  residue 
(one-quarter  of  the  original  meal)  beyond  six  hours  and  the  patient 
has  taken  no  food  or  drugs  in  the  meantime,  one  must  suspect  a 


Fig.  146. — Tracing  of  the  stomach,  showing  annular  constriction  of  the  media  ckie  to 

cancer. 

lesion  in  the  stomach,  reflex  irritation  of  the  pylorus  (duodenum, 
gall-bladder,  appendix)  or  obstruction  in  the  intestine  below.  In 
rare  instances  delay  may  be  due  to  acute  illness,  marked  ptosis  or 
the  action  of  certain  drugs. 

Carcinoma. — Because  of  the  insidious  onset  of  carcinoma,  the 
patients  do  not  appear  for  examination  until  there  is  a  well-estab- 
lished lesion  so  that  few  early  ones  are  found.  The  characteristic 
findings  are  defects  in  outline,  absent,  sluggish,  irregular  or  reversed 


STOMACH  169 

peristalsis,  esophageal  or  gastric  stasis  (or  early  gastric  emptying) 
and  loss  of  flexibility  of  stamach  wall.  The  appearances  seen  vary 
considerably  with  the  t}^e  of  growth  and  with  its  location.  Car- 
cinoma of  the  cardia  is  often  difficult  to  visualize.  In  these  cases 
it  is  helpful  to  watch  the  first  mouthfuls  of  barium  entering  the 
stomach.  The  jet  will  be  irregular  instead  of  smooth  and  there 
may  be  delay  at  the  cardia.  There  will  also  be  rigidity  and  deformity 
of  the  fundus  which  does  not  change  on  deep  inspiration.  For  this 
observation  the  patient  should  lie  on  his  back. 


Fig.  147. — Extensive  malignant  disease  of  the  media  and  antrum. 

Large  growths  in  the  body  and  antrum  are  usually  characteristic. 
There  is  a  ragged  annular  defect  which  is  constant  at  all  times  and 
in  all  positions.  If  the  tumor  is  palpable  it  will  be  found  to  coincide 
with  the  defect.  Peristalsis  is  absent  in  the  region  of  the  growth 
and  may  be  irregular,  sluggish  or  reversed  elsewhere.  Stasis  is  usual. 
The  dift'erentiation  is  from  ulcer,  lues,  adhesions  and  extragastric 
tumors.  Typical  ulcers  and  t\T)ical  carcinoma  are  easily  distin- 
guishable but  borderline  cases  are  often  hard  to  identify.    Carcino- 


170 


GASTRO-INTESTINAL  TRACT 


matous  ulcers  may,  like  benign  ulcers,  be  limited  to  one  wall  and 
show  a  rigid  area  of  infiltration  with  the  pocket  of  a  crater  project- 
ing from  it.     However,  the  crater  is  usually  larger  in  carcinoma  and 


Pl/lOT'U  S 


FiG.  148. — Extensive  annular  involvement  of  the  media  and  antrum  due  to 
malignant  disease. 


Fig.  149. — Malignant  disease  of  the  pyloric  end  of  the  stomach. 


STOMACH 


171 


peristalsis  will  be  diminished  or  irregular,  while  in  ulcer  it  is  apt 
to  be  increased.  Stasis  may  occur  in  both  cases  but  is  perhaps 
more  frequent  in  ulcer.  Spasms  and  incisurae  are  much  more 
common  in  ulcer. 

In  lues  the  deformity  is  generally  more  irregular  and  the  patient 
is  not  so  sick  as  he  would  be  if  the  lesion  were  carcinomatous.  The 
defect  is  out  of  proportion  to  the  symptoms. 


Fig.  150. — Malignant  disease  of  the  cardia,  with  metastasis  in  tlie  lungs. 


The  defects  in  adhesions  and  extragastric  tumors  are  usually 
not  constant  in  all  positions. 

Diffuse  infiltration  of  the  stomach  wall  occurs  in  scirrhous  car- 
cinoma, lues  and  linitis  plastica  (which  may  be  one  form  of  lues). 
The  signs  are  those  of  infiltration — a  smooth,  rigid  outline  with 
absence  of  peristalsis  and  usually  a  contracted,  rapid  emptying 
stomach. 

Pyloric  Carcinoma.- — In  well-established  cases  there  is  a  definite 
funnel-shaped  defect  and  if  the  pj'lorus  is  involved,  the  outlet 


172 


GASTRO-INTESTINAL  TRACT 


becomes  rigid  and  the  stomach  may  empty  rapidly.  Dilatation  of 
the  stomach  is  rarely  present.  In  early  carcinoma  at  the  pylorus 
there  may  be  a  funnel-shaped  defect  which  is  not  due  to  the  actual 
lesion,  probably  as  a  result  of  associated  spasm. 

Ulcer, — In  general,  ulcers  are  more  readily  found  the  closer  they 
are  to  the  pylorus.  Stasis  is  of  more  significance  the  nearer  the 
lesion  lies  to  the  sphincter,  i.  e.,  if  there  is  pyloric  deformity  and  no 


Fig.  151. — Tracing  of  stomach,  showing  typical  deformity  of  cap  due  to  duodenal 

ulcer. 


residue,  it  is  not  due  to  ulceration  but  to  some  other  condition,  most 
commonly  carcinoma  or  adhesions.  The  recognition  of  an  ulcer 
depends  upon  the  presence  of  a  crater  which  can  be  filled  with 
barium  and  brought  into  profile  and  upon  the  presence  of  associated 
spasm,  increased  peristalsis  and  usually  stasis.  In  some  cases  the 
crater  and  spasm  are  absent  although  careful  observation  may  reveal 
the  presence  of  a  small  area  of  induration  indicated  by  a  break  in 
peristalsis,  or  there  may  be  no  discoverable  abnormality  aside  from 


Pylorus 


Fig.  152. — Tracing,  showing  type  of  duodenal  ulcer. 


Fig.  153. — Tracing,  showing  type  of  duodenal  ulcer. 


174 


GASTRO-INTESTINAL  TRACT 


Fig.  154. — Tracing  of  stomach,  showing  the  deep,  vigorous  peristalsis  of  duodenal 

ulcer. 


Fig.  155. — Tracing  of  the  stomach,  showing  stoma  and  position  of  bismuth  in  email 
bowel  after  gastro-enterostomy. 


STOMACH 


175 


a  residue.  However,  the  latter  are  not  usually  surgical  ulcers  so  that 
failure  to  identify  them  is  not  of  as  great  importance.  Ulcers  may 
be  divided  into  mucous,  indurated,  penetrating  and  perforating. 

The  mucous  t;>"pe  is  usually  indicated  by  an  incisure  opposite 
the  lesion  and  may  or  may  not  have  accompanying  hA-perperistalsis 
and  stasis.    They  are  often  missed. 


Fig.  156. — Duodenal  ulcer  shoviing  typical  deformity. 


In  the  indurated  form,  one  sees  an  area  of  infiltration  on  the 
lesser  curvature  which,  if  extensive,  may  cause  considerable  shorten- 
ing of  this  curvature.  There  will  be  a  break  in  peristalsis  at 
the  site  of  the  lesion,  h^-perperistalsis  and  stasis.  Spasm  is  not 
usually  present.  \Yhen  it  does  occur  it  takes  the  form  of  local 
incisurse  opposite  the  active  edge.  They  may  cause  irregularity  of 
the  greater  curvature  from  contraction  of  scar  tissue  which  extends 
out  around  the  body  of  the  stomach.  If  they  occur  at  the  pylorus 
there  is  failure  of  the  antrum  to  contract  and  stasis  is  marked.    The 


176  GASTRO-INTESTINAL  TRACT 

first  swallow  of  barium  may  collect  in  a  small  pool  at  the  site  of  the 
lesion  due  to  the  slight  spasm  which  holds  up  its  progress  at  first 
but  which  disappears  as  the  stomach  fills. 

Penetrating  ulcers  have  all  the  signs  of  the  indurated  form  and, 
in  addition,  a  mass  of  barium  projecting  from  the  rigid  area  which 
corresponds  in  size  and  shape  with  the  crater  of  the  lesion.  Although 
they  are  often  found  on  the  posterior  wall  surgically,  they  usually 
appear  on  the  lesser,  curvature  during  the  roentgen  examination. 
A  lateral  ^'iew  may  at  times  be  necessary  to  adequately  visualize 
these  lesions  and  should  be  a  part  of  the  routine  examination  which 
as  a  matter  of  fact  should  include  careful  observation  from  every 


Fig.    157- — Free   gas   between  the  upper  surface   of  the  liver   and  the   diaphragm 
following  perforation  of  a  duodenal  ulcer. 


angle  in  at  least  three  positions — prone,  supine  or  standing.  These 
protrusions  must  be  differentiated  from  the  duodenojejunal  flexure 
which  is  often  projected  just  above  the  lesser  cur\'ature.  Rotation 
of  the  patient  and  deep  inspiration  will  usuall}^  enable  one  to  deter- 
mine whether  or  not  the  mass  is  actually  projecting  from  the  gastric 
shadow  or  is  independent  of  it. 

Perforating  ulcer  shows,  in  addition  to  the  signs  of  a  penetrating 
ulcer,  the  presence  of  a  gas  bubble  outside  the  stomach  wall  above 
the  mass  in  the  crater. 

Syphilis. — Its  radiographic  appearance  is  practically  that  of  car- 
cinoma except  that  mottling  of  the  barium  mass  and  stasis  are 


STOMACH  111 . 

uncommon.  The  extent  of  the  lesion  is  out  of  proportion  to  the 
patient's  s}Tnptoms.  The  age  of  the  patient,  the  history  and  the 
laboratory  findings  must  be  relied  upon  for  corroborative  evidence. 
Appropriate  treatment  improves  sjTQptoms  and  may  or  may  not 
affect  the  roentgen  picture. 


Fig.  158. — Postoperative  ulcer  of  the  stomach  (recurrent).  The  constriction  is 
probably  the  result  of  the  operation.  The  projection  just  below  it  is  the  crater  of  a 
new  ulcer. 


Linitis  Plastica. — ^Linitis  plastica  is  believed  by  some  observers  to 
be  a  late  stage  of  a  luetic  process.    It  is  a  fairly  rare  condition  in 
which  the  gastric  wall  is  infiltrated  by  dense  fibrous  tissue  which 
12 


178 


GASTRO-INTESTINAL  TRACT 


contracts  the  stomach  down  to  a  sniall,  rigid  tube  high  up  under 
the  liver,  and  through  which  the  meal  pours  in  a  few  minutes. 

Foreign  Bodies. — Hair  balls  and  metal  articles  are  occasionally 
reported.  Whether  or  not  they  are  in  the  stomach  may  be  deter- 
mined by  changing  the  position  of  the  patient,  by  inflating  the 
stomach  with  air  and  the  routine  barium  meal.  Hair  balls  present 
a  characteristic  appearance  and  the  barium  adheres  to  them,  out- 
lining their  structure  for  some  time  after  the  meal  has  passed  on. 


Fig.  159. — Specific  stomach. 


Polypi. — Polypi  of  the  gastric  wall  are  comparatively  rare.  They 
may  be  multiple  and  when  demonstrable,  appear  as  smooth,  rounded 
holes  in  the  barium  shadow  which  remain  constant  with  changes 
in  the  position  of  the  patient.  Peristaltic  waves  are  not  interfered 
with.  The  condition  must  be  differentiated  from  foreign  materials 
in  the  stomach,  such  as  food  masses  and  from  extragastric  tumors. 


STOMACH 


179 


Their  constancy  is  the  best  evidence.  In  the  late  stages,  if  extensive, 
they  may  cause  obstruction  and  be  mistaken  for  mahgnancy. 

The  stomach  after  gastro-enterostomy  is  usually  smaller  and 
higher.  It  empties  rapidly,  depending  somewhat  upon  the  size  of 
the  stoma.  There  is  little  peristalsis  visible.  When  seen  it  usually 
passes  over  the  entire  lower  part  of  the  stomach  to  the  pylorus, 
forcing  the  barium  mixture  through  unless  it  has  been  closed  at 


Fig.  160. — Dilatation  of  the  jejunum  due  to  obstruction  from  malignant  disease. 


the  operation  or  by  disease.  Usually  the  stoma  can  be  demon- 
strated and  its  size,  position  and  contour  noted.  A  loop  of  the 
jejunum  passing  from  behind  the  stomach  shadow  ma}'  lead  to  errors. 
The  observations  to  be  made  in  the  order  of  their  importance  are 
emptying  time ;  shape  and  position  of  the  stoma ;  type  of  peristalsis ; 
size  of  stomach;  whether  or  not  food  leaves  through  the  pylorus, 
and  the  appearance  of  the  duodenal  loop. 


180  GASTRO-INTESTINAL  TRACT 


DUODENUM. 


The  normal  first  part  of  the  duodenum  is  a  smooth,  rounded, 
triangular  shadow,  at  times  connected  with  the  stomach  by  a  thin 
line  of  barium  in  the  pyloric  canal  when  the  sphincter  is  open.  Its 
relation  to  stomach,  gall-bladder  and  liver  varies  with  the  type  and 
position  of  the  patient  and  the  size  and  shape  of  the  stomach  and 
liver.  It  has  a  peristalsis  of  its  own  and  its  filling  and  emptying 
are  controlled  both  by  the  pyloric  sphincter  and  a  constrictive  action 
of  the  junction  of  the  first  and  second  portions.  The  rapidity  of 
filling  and  emptying  depends  largely  upon  the  character  of  the  meal, 
being  much  more  rapid  in  the  case  of  watery  and  carbohydrate 
mixtures  than  when  proteins  are  present.  It  may  be  considerably 
enlarged  in  atonic  individuals.  Enlargement  may  also  occur  as  a 
result  of  adhesions  or  bands  about  the  duodenum  or  ulcer  of  the 
second  portion.  It  may  be  contracted  as  a  result  of  spasm,  scar 
tissue  in  the  wall  or  adhesions  about  it.  Defects  in  outline  ma}'  be 
due  to  pressure  as,  for  example,  smooth  rounded  depression  due  to 
the  gall-bladder  and  the  small  indentation  on  the  inner  margin  due 
to  the  bile  duct.  Scars  and  the  spasm  from  ulcers  cause  irregular 
deformities  which  produce  the  familiar  coral-shaped  shadow. 
Rarely,  as  a  result  of  perforation  of  such  an  ulcer,  there  may  be  a 
pocket  filled  with  barium  between  the  duodenum  and  the  liver  or 
colon.  In  some  cases  of  perforation,  free  gas  has  been  demonstrated 
in  the  peritoneum  above  the  liver.  Adhesions  usually  produce  slight 
irregularities  which  are  not  constant.  Spasm  may  produce  exten- 
sive changes  in  the  shape  of  the  duodenal  bulb.  It  is  usually  reflex 
from  a  lesion  of  the  gall-bladder  or  the  appendix.  Yery  rapid  empty- 
ing where  the  meal  shoots  through  the  cap  rapidly  is  seen  in  gastric, 
pyloric  and  duodenal  ulcer.  Delayed  emptying  may  be  due  to 
obstruction  in  the  duodenum  or  the  intestine  lower  down,  but  usuall}^ 
occurs  reflexly  as  a  result  of  gall-bladder  or  appendiceal  disease. 

Ulcer. — The  signs  of  ulcer  are  deformities  in  outline,  changes  in 
motility  already  mentioned,  in  addition  to  changes  in  gastric  per- 
istalsis and  motility.  The  deformities  in  outline  must  be  differen- 
tiated from  those  due  to  spasm  as  a  result  of  gall-bladder  or  appendix. 
The  deformity  of  ulcer  is  constant,  whereas  that  due  to  spasm  will 
vary  or  disappear  at  different  examinations.  It  is  probable  that  a 
part  of  the  deformity  seen  in  duodenal  ulcer  is  due  to  local  spasm 
accompanying  the  lesion. 


ILEUM  181 

Adhesions. — Adhesions  may  produce  slight  irregularities  in  the 
cap  which  are  not  constant  with  change  in  position  of  the  patient 
and  there  is  usually  fixation  of  the  bulb.  Constricting  bands  may 
be  fomid  am'^\'here  in  the  course  of  the  duodenum.  E^'idence  of 
their  presence  is  seen  in  dilatation  and  delay  in  motility,  a  common 
form  of  which  is  the  pendulum  movement  of  masses  of  barium  to 
and  fro  in  the  second  and  third  portions.  The  meal  passes  as  a 
flocculated  mass  through  the  second  and  third  portions  of  the 
duodenum  with  considerable  rapidity  so  that  they  are  less  well 
outlined  than  the  first  portion.  The  entire  second  and  third  por- 
tions are  well  outlined  only  when  there  is  a  rapidly  emptying 
stomach  or  in  cases  of  obstruction  from  adhesions  or  pancreatic 
disease.  Delay  in  any  portion  of  the  duodenum,  pendulum  move- 
ments of  the  barium  mass,  visible  and  reverse  peristalsis  are  sug- 
gestive of  spasm  or  obstruction.  Ulcer  is  rare  in  this  portion  of  the 
duct  although  craters  have  been  seen.  The  ampulla  of  Vater  may 
be  dilated  and  appear  as  a  definite  spot  of  barium  a  few  millimeters 
in  diameter  along  the  descending  portion.  Diverticula  are  occa- 
sionally seen.  They  appear  as  rounded  masses  in  close  proximity 
to  the  duodenum.  Duodeno-gall-bladder  fistulte  have  been  dem- 
onstrated. 

JEJUNUM. 

The  jejunum  normally  appears  as  coils  of  fine,  feathery  flakes 
of  the  meal  due  to  the  rapidity  of  its  progress.  It  is  never  outlined 
except  in  pathological  conditions,  the  most  common  of^which  are 
peritonitis,  acute  or  chronic,  and  obstruction  from  bands  or  tumors. 
A  tumor  sufficient  to  cause  obstruction  is  nearly  always  palpable. 
In  peritonitis  and  obstruction  the  flocculent  appearance  is  lost  and 
the  coils  are  dilated.  Gastrojejunal  ulcers  may  occasionally  be 
made  out  at  the  site  of  gastro-enterostomy.  They  appear  as  per- 
sistent irregularity  in  outline  in  the  region  of  the  stoma  which  are 
sometimes  rather  diflficult  to  visualize.  Changes  in  gastric  peris- 
talsis and  motility  are  the  rule. 

The  roentgen  evidences  of  gastrojejunal  ulcer  are  gastric  stasis, 
increased  gastric  peristalsis,  deformity  of  the  stoma,  and  localized 
tenderness. 

ILEUM. 

The  Qormal  ileum  is  seen  as  a  coil  of  intestine  containing  dense  masses 
of  barium  lying  low  in  the  pelvis  with  a  loop  running  up  to  terminate 


182  GASTRO-INTESTINAL  TRACT 

in  the  cecum.  Palpation  is  unsatisfactory  except  in  its  terminal 
portion  owing  to  its  depth  in  the  pelvis.  It  is  smooth  in  outline 
with  transverse  contractions  which  are  continually  changing.  It 
may  begin  to  fill  within  an  hour  after  the  meal  has  reached  the 
stomach  and  is  entirely  emptied  by  eight  to  ten  hours  after  eating. 
The  head  of  the  meal  should  have  passed  through  it  at  six  hours. 
Dilatation  occurs  as  a  result  of  obstruction  from  adhesions  or  bands. 
Disease  in  the  ileocecal  region  usually  causes  fixation  and  tender- 
ness of  the  terminal  ileum.  A  delay  of  over  six  hours  in  entering  the 
cecum  or  beyond  ten  hours  for  complete  emptying  of  the  ileum  is 
suggestive  of  disease  in  the  ileocecal  region,  in  which  case  there  is 
usually  an  associated  fixation  and  tenderness  of  the  terminal  ileum. 

APPENDIX. 

The  normal  appendix  fills  and  empties  during  the  presence  of 
barium  in  its  vicinity  and  should  be  visible  if  persistently  and  care- 
fully looked  for.  It  is  freely  movable  and  not  tender  and  should 
be  empty  when  the  cecum  has  emptied.  It  may  present  one  or  more 
constrictions  which  are  without  significance.  When  it  is  or  has 
been  the  seat  of  disease,  it  either  never  fills  or  fills  irregularly  and 
contains  a  residue  after  the  cecum  is  empty.  There  may  also  be 
tenderness  and  fixation  of  cecum  and  terminal  ileum,  stasis  in  the 
ileum,  stasis  and  hyperperistalsis  in  the  stomach,  spasm  of  the 
duodenum,  and  at  times  stasis  in  the  tip  of  the  cecum  after  a  meal 
and  after  enema.  An  incompetent  ileocecal  valve  is  often  associated 
with  such  an  appendix.  Stones  and  foreign  bodies  are  sometimes 
demonstrated  in  appendices  and  may  be  mistaken  for  ureteral  stones. 

CECUM. 

The  normal  cecum  is  smooth  with  transverse  constrictions  and 
is  freely  movable  vertically  and  laterally  but  varies  greatly  in  size, 
position  and  mobility.  A  filled  terminal  ileum  is  often  necessary 
to  identify  it  positively.  It  may  be  dilated  in  cases  of  obstruction 
in  the  distal  colon  or  in  spastic  constipation.  It  may  be  contracted 
by  extensive  adhesions  about  it.  Changes  in  outline  which  are  best 
demonstrated  by  enema  are  due  to  adhesions,  to  carcinoma  which 
produces  large,  irregular  defects,  or  to  inflammatory  masses  as  a 
result  of  tuberculosis  or  a  chronic  appendix,  which  may  produce  large 
defects  resembling  carcinoma,  but  (iareful  observation  will  usually 


COLON 


183 


show  them  to  be  outside  the  colon.     The  normal  cecum  is  never 
empty  when  barium  is  present  in  both  ileum  and  ascending  colon. 

COLON. 

The  colon  varies  greatly  in  size  and  po3?cion  from  hour  to  hour 
and  in  different  individuals.  The  outline  is  smooth  and  broken  by 
haustrel  segmentations.  The  meal  normally  reaches  the  splenic 
flexure  in  twelve  to  eighteen  hours  and  the  colon  is  entirely  clear 


Fig.   161. 


-Carcinoma  of  the  transverse   colon.     On  the  opposite  side  there  is 
narrowing  of  the  gut,  due  to  periostitis. 


in  from  twenty-four  to  seventy-two  hours.  ]\Io^'ements  of  the  colon 
are:  (1)  haustrel  churning,  that  is,  formation  and  reformation  of 
haustrel  contractions  and  (2)  antiperistalsis  or  anastalsis.  A  con- 
traction ring  exists  at  about  one-third  of  the  distance  between  the 


184 


G ASTRO-INTESTINAL  TRACT 


hepatic  and  splenic  flexures  and  from  this  point  antiperistaltic 
Avaves  run  slowly  backward  to  the  cecum.  (3)  Pendulum  move- 
ments where  large  masses  of  contents  swing  back  and  forth  through 
short  distances;  they  are  usually  soon  followed  by  (4)  mass  move- 
ments where  haustrel  markings  disappear  and  large  masses  of  barium 
are  rapidly  propelled  through  a  considerable  portion  of  the  colon. 
In  outlining  the  colon  by  enema  it  takes  a  few  minutes  to  complete 


Fig.  162. — Hirschprung's  disease.     Idiopathic  dilatation  of  the  colon. 


the  filling  of  the  rectum  and  sigmoid,  after  which  the  fluid  should  run 
over  readily  to  the  cecum.  The  pelvic  loop  of  the  sigmoid  as  it 
distends  should  rise  well  out  of  the  pelvis.  If  it  is  retained  in  the 
pelvis,  pelvic  adhesions  should  be  suspected. 

Variations. — The  position  of  the  colon  may  be  reversed  so  that 
the  ascending  colon  lies  on  the  left  side  in  cases  of  transposition 
of  viscera  and  it  may  not  rotate  completely  during  the  process  of 


COLON  185 

development,  or  the  ascending  colon  may  not  be  completely  formed 
so  that  the  cecum  lies  in  the  region  of  the  gall-bladder.  The  sig- 
moid is  subject  to  great  ^'ariation  in  length  and  amount  of  omentum. 
In  cases  of  so-called  redundant  sigmoid  it  may  be  found  an}"\vhere 
iti  the  abdomen. 

Changes  in  Size. — The  colon  may  be  dilated  as  a  result  of  con- 
genital malformations,  so-called  megacolon  or  Hirschprung's  dis- 
ease, or  as  a  result  of  obstruction  from  bands  or  tumors.  The 
'caliber  of  the  transverse  and  descending  portions  is  uniform!}' 
diminished  in  spastic  constipation. 

Changes  in  Position. — Changes  in  position  are  not  important  unless 
they  are  permanent  and  fixed  as,  for  example,  sigmoid  to  the  gall- 
bladder region  or  the  appendix  region. 

Changes  in  Outline. — In  observations  after  barium  meals  the 
colon  will  often  show  irregular  defects  due  to  the  presence  of  fecal 
matter.  They  are  not  permanent  and  in  case  of  doubt  an  opaque 
enema  will  rule  out  pathology.  Defects  are  seen  best  after  enema. 
The  common  ones  are  the  annular,  ragged,  funnel-shaped  deformi- 
ties due  to  carcinoma  and  the  constrictions  caused  by  bands  of 
adhesions.  Multiple  small  buds  are  sometimes  seen  along  the  course 
of  the  colon,  particularly  in  its  descending  portion,  which  represent 
barium-filled  diverticulae.  They  may  be  overlooked  if  the  only 
observation  of  the  colon  is  twenty-four  hours  after  the  meal.  The 
barium-filled  colon  may  overlap  and  obscure  them  so  that  where 
their  presence  is  suspected  the  patient  should  be  seen  after  the  colon 
is  empty,  as  small  residues  may  remain  in  the  diverticulse  for  se^■eral 
days  after  the  colon  is  clear  as  small,  round,  dense  masses  scattered 
along  the  course  of  the  colon.  They  are  sometimes  brought  out  by 
an  enema  when  a  meal  has  failed  to  reveal  their  presence.  It  has 
been  noted  that  there  is  a  complete  absence  of  segmentation  in 
severe  cases  of  colitis. 

Changes  in  Motility. — Decreased  emptying  time  occurs  in  achylia, 
in  conditions  which  produce  a  rigid,  incompetent  pylorus,  and  in 
colitis.  Increased  emptying  time  or  constipation  appears  usually 
in  three  forms,  spastic,  atonic  and  rectal.  The  spastic  type  is  the 
result  of  increased  tone  of  the  transverse  and  descending  colon 
shown  by  a  diminution  in  caliber  and  changes  in  haustrel  segmen- 
tations which  are  fewer  in  number  and  increased  in  width.  The  delay 
in  these  cases  may  be  extreme,  barium  remaining  in  the  colon  as 
late  as  a  week  after  the  meal.  The  atonic  t}'pe  is  characterized  by 
a  large,  flabby  colon  and  is  comparatively  rare.    It  may  be  seen  in 


186  GASTRO-'INTESTINAL  TRACT 

asthenic  states  where  there  is  a  general  loss  of  tone.  In  the  rectal 
type  there  are  large  masses  of  barium  high  up  in  the  rectum  and 
sigmoid  occupying  most  of  the  pelvis.  There  is,  of  course,  more  or 
less  dela}^  in  cases  of  obstruction  due  to  adhesions  or  malignancy. 

EECTUM. 

The  rectum  appears  as  a  smooth,  S-shaped  mass,  occupying  a 
considerable  portion  of  the  pelvis.  Defects  in  outline  are  due  to 
carcinoma  which  show  the  ragged,  annular  lesions  typical  of  the 
disease,  llceration  due  to  lues  or  tuberculosis  may  be  evidenced 
by  more  or  less  infiltration  of  the  wall  which  becomes  rigid.  The 
diameter  of  the  intestine  is  diminished  rather  uniformly  throughout 
the  area  of  the  lesion.  Pressure  from  inflammatory  masses  or  tumor 
in  the  pelvis  may  deform  or  displace  the  rectal  shadow. 


Fig.  163. — This  plate  shows  a  fairly  typical  group  of  gall-stone  shadows. 

GALL-BLADDER. 

Visualization  of  the  gall-bladder  is  a  matter  of  thorough,  careful 
technic  and  a  certain  amount  of  luck.  The  patient  must  suspend 
respiration  completely  and  the  exposure  and  position  of  the  central 


GALL-BLADDER  187 

ray  may  be  just  right  for  the  particular  patient.  It  is  an  exaggera- 
tion to  say  that  every  gall-bladder  which  can  be  visualized  is  patho- 
logical. However,  it  is  undoubtedly  true  that  a  large  proportion 
of  pathological  gall-bladders  can  be  visualized  by  careful  work. 
The  shadow  of  the  gall-bladder  is  rounded  and  sharply  margined; 


Fig.  164. — The  indefinite  ring-like  shadow  between  the  eleventli  and  twelfth 
vertebrae  is  that  of  a  single  large  gall-stone. 

it  varies  greatly  in  size  and  position;  it  may  be  found  an\'^vhere 
from  the  costal  margin  to  the  crest  of  the  ilium.  Gall-stones  may 
be  recognized  if  they  contain  a  sufficient  amount  of  calcium  salts, 
which  unfortunately  is  true  in  only  20  to  30  per  cent,  of  the  cases. 
They  appear  as  single  or  multiple  shadows  which  may  be  the 
typical  faint  ring,  a  dense  homogeneous  mass,  or  a  mottled  area 


188  GASTRO-INTESTINAL  TRACT 

of  density  due  to  many  small  stones  packed  together.  Great  care 
must  be  taken  to  resist  the  tendency  to  make  positive  diagnosis 
of  gall-stones  from  any  faint  shadows  in  the  gall-bladder  region. 
Shadows  of  stones  are  often  very  faint  but  they  at  least  should 
show  definite  rings  and  lie  entirely  within  the  limits  of  the  gall- 
bladder before   they   can   be   diagnosed   as   stones.     The    proper 


Fig.  165. — The  large  indefinite  shadow  near  the  spine  is  not  a  gall-stone,  as  nothing 
was  found  at  operation.    It  is  probably  a  retroperitoneal  gland. 

significance  of  the  negative  diagnosis  should  be  realized  and 
insisted  upon  at  all  times.  A  negative  diagnosis  is  of  no  positive 
value,  for  stones  may  be  present  and  cast  no  shadow.  Further- 
more, the  patient's  symptoms  may  be  due  more  to  associated 
pathology  in  the  gall-bladder  than  to  the  stones.  Patients  occa- 
sionally refuse  a  needed  operation  because  stones  have  not  been 
demonstrated  by  the  roentgen  method.      They  should  be  warned 


BIBLIOGRAPHY  189 

in  the  beginning  that  gall-stones  may  not  show.    When  gall-bladder 
disease  is  suspected,  a  routine  gastro-intestinal  examination  should 


Fig.  166. — Calcified  retroperitoneal  glands  resembling  a  gall-stone. 

always  be  done  to  determine  the  incidence  of  adhesions  and  reflex 
gastric  disturbances  such  as  spasm  or  stasis. 

BIBLIOGRAPHY. 

Cannon,  W.  B.:   The  mechanical  factors  of  digestion,  New  York,  Longmans,  1911. 

Williams,  F.  W. :   Roentgen  rays  in  medicine  and  surgery.  New  York,  1903. 

Carman,  R.  D.,  and  Miller,  A.:  Roentgen  diagnosis  of  disease  of  the  alimentary 
canal,  Philadelphia,  1917. 

Holzknecht:  G.:  Recent  advances  in  the  Roentgen  examination  of  the  digestive 
tract,  Berl.  klin.  Wchnschr.,  1911,  No.  4;    Arch.  Roent.  Ray,  .July,  1912. 

Holzknecht,  G.:  Roentgen  diagnosis  of  the  stomach.  Arch.  Roent.  Ray,  1911, 
xiv,  p.  206. 

Holzknecht,  G.:  Der  normale  Magen  nach  Form,  Lage  und  Grosse,  Mitt.  a.  d. 
Lab.  f.  Rad.  Diag.,  1906,  i,  p.  72. 

Holzknecht,  G.:  Die  normal  Peristaltik  des  Colon,  Miinchen.  med.  Wchnschr., 
1909,  ha,  part  2,  p.  2401;   Arch.  Roent.  Ray,  1909-10,  xiv,  p.  273. 

Holzknecht,   G.:    See  p.  2. 

Holzknecht,  G.,  and  Luger,  A.:  Zur  Pathologic  u.  Diagnostik  des  Gastrospasmus, 
Mitt,  a,  d.  Grenz.  der  Med.  u.  Chir.,  1913,  xx^-i,  p.  669. 


190  GASTRO-INTESTINAL  TRACT 

Holzknecht,  G.,  and  Sgalitzer,  M.:  Papaverin  zur  roentgenologischen  Differential- 
diagnose  z-ndschen  Pylorospasmus  und  Pylorusstenose,  Mimchen.  med.  Wchnschr., 
1913,  Ix,  p.  1989. 

Ringer  G.,  and  Holzknecht,  G.:  Radiologische  Anhaltspunkte  zur  Diagnose  der 
chronischen  Appendizitis,  Miinchen.  med.  Wchnschr.,  1913,  ii,  p.  26.59. 

Hertz,  A.  F. :    Constipation  and  allied  disorders,  London,  1909. 

Hertz,  A.  F.:   Chronic  intestinal  stasis,  British  Med.  .Jour.,  1913,  i,  p.  817. 

Hertz,  A.  F. :  AT-ray  diagnosis  of  gastro-intestinal  conditions,  with  special  refer- 
ence to  appendicitis,  Arch.  Roent.  Ray,  1914,  xix,  p.  249. 

Case'  J.  T.:  Stereoroentgenography  of  the  alimentary  canal,  4  parts,  Troj',  New 
York,  1914-15. 

Codman,  E.  A.:  Diagnosis  of  diseases  of  the  stomach  and  intestines  by  the  x-ray, 
British  Med.  Surg.  Jour.,  1912,  clx^-i,  p.  155. 

Leonard,  C.  L.:  Radiography  of  the  stomach  ajid  intestines,  Am.  Jour.  Roent., 
1913,  i,  p.  5. 

Beclere  (Paris) :  Les  Rayons  de  Roentgen  et  le  diagnostic  des  affections  thora- 
ciques,  Paris. 

Beclere:  Rapport  sur  I'exploration  radiologique  dans  les  affections  chlrurgicales 
do  I'estomac  et  de  I'intestin,  Tr.  Assn.  Frangaise  de  Chir,  October,  1912. 

Holzknecht,  G.:  Das  norniale  roentgenologische  Verhalten  des  Duodenum, 
Zentralbl.  f.  Physiol,  1909,  xxiii,  p.  974. 

Case,  J.  T.:  Roentgenologic  aspects  of  intestinal  stasis,  Med.  Clinics,  Chicago, 
1915-16,  i,  p.   829. 

Keith,  A.:  Interpretation  of  certain  a--ray  signs  of  intestinal  stasis,  Proc.  Roy. 
Soc.  Med.,  Electrotherapeutic  Section,  1915. 

Hertz,  A.  F.:   Ileocecal  sphincter,  Jour.  Physiol.,  1913-14,  xlvii,  p.  54. 

Hertz,  A.  F.,  and  Ne'v\i;on,  A.:  Normal  movements  of  the  colon,  Jour.  Physiol., 
1913-14,  xlvii,  p.  57. 

Barrett,  G.  M.:   Linitis  plastica.  Jour.  Am.  Med.  Assn.,  1916,  Ixvii,  p.  276. 

Cole,  L.  G.:  The  diagnosis  of  post-pyloric  (duodenal)  ulcer  by  means  of  serial 
radiography.  Lancet,  1914,  R.  44,  p.  1239. 

Imboden,  H.  M.:  Roentgen  diagnosis  of  lesions  of  the  vermiform  appendix. 
Am.  Jour.  Roent.,  1915,  ii,  pp.  581-91. 

Pf abler,  G.  E. :  The  Roentgen  ray  in  the  diagnosis  of  gall-stones  and  cholecystitis. 
Jour.  Am.  Med.  Assn.,  1914,  cxiii,  pp.  304-6. 

Barclay,  A.  E.:    The  stomach  and  esophagus,  Macmillan  Company,  New  York. 

Caldwell,  E.  W. :  The  safe  interpretation  of  roentgenograms  of  the  gall-bladder 
region.  Am.  Jour.  Roent.,  1915,  ii,  pp.  816-819. 

Schwarz,  G.:  Roentgen  shadow,  with  chronic  gastritis,  Wien.  klin.  "Wchnschr., 
1916,  xxix,  p.  1554. 

McMahon,  F.  B.,  and  Russell,  D.  C:  Chronic  colitis  and  its  roentgenologic 
findings.  Jour.  Lab.  and  Clin.  Med.,  ii,  p.  328. 

Basch,  Seymour:  Diverticulum  of  the  duodenum.  Am.  Jour.  Med.  Sc,  1917, 
clxxx,  p.  83.3. 

Geis:   Acute  tuberculosis  of  the  stomach,  Long  Island  Med.  Jour.,  1916,  p.  84. 

Sailer,  J.:    Linitis  plastica,  Am.  Jour.  Med.  Sc,  1916,  cli,  p.  321. 

Le  Wald:   Pyloric  stenosis.  Am.  Jour.  Obst.,  1916,  p.  1162. 

Baetjer,  F.  H.,  and  Friedenwald:  Roentgen  ray  in  gastric  cancer,  Johns  Hopkins 
Hosp.   Bull.,    1916,   xx^-ii,   p.   221. 

Kerley,  C.  G.,  and  Le  "Wald,  L.  T.:  Digestive  disorders  in  children.  Jour.  Am.  Med. 
Assn.,  1916,  IxAdi,  p.  1569. 

Homans,  J.:  Congenital  transduodenal  bands,  British  Med.  Surg.  Jour.,  1916, 
clxxv,   p.   665. 

White,  F.  W.:  Syphilis  of  the  stomach,  British  Med.  Surg.  Jour.,  1917,  clxx\'i,  p.  11. 

Eusterman,  G.  B.:   Sj'philis  of  the  stomach.  Am.  Jour.  Med.  Sc,  1917,  cliii,  p.  21. 

Smithies,  F.:  -SjTjhilis  of  the  stomach.  Am.  Jour.  Syph.,  1917,  i,  p.  100. 

Cadwallader,  R.:   Hirschpi-ung's  disease.  Arch.  Ped.,  1916,  xxxiii,  p.  665. 

Basch:  Primary  benign  gro\si;hs  in  the  stomach,  Tr.  Am.  Gast.-Intest.  Assn., 
1915,  xviii,  p.  37. 

Stewart,  W.  H.:  The  value  of  the  roentgen  examination  in  obstruction  of  the 
esophagus.  Arch,  of  Diag.,  1913,  ^ri,  pp.  309-314. 

Mills,  R.  Walter:  "The  Relation  of  Bodily  Habitus  to  Visceral  Form,  Position, 
Tonus  and  Motility."     Amer.  Jour.  Roent,,  April,  1917. 


CHAPTER   IX. 
GEXITO-URIXARY  TRACT. 

Preparation  of  the  Patient. — The  preliminary  preparation  of  the 
patient  is  a  matter  of  opinion.  If  it  is  thought  advisable,  a  vege- 
table cathartic  or  oil  should  always  be  recommended.  Mineral 
salts  and  enemata  are  particularly  to  be  avoided,  the  former  because 
of  their  tendency  to  fill  the  intestine  with  fluid  and  the  latter  because 
they  are  seldom  entirely  expelled  and  air  is  usually  introduced  along 
with  them.  Fluid  or  air  in  the  intestine  may  entirely  obscure  the 
kidneys  and  cause  a  confusing  shadow.  Excellent  plates  may  often 
be  obtained  with  no  preparation. 

Technic. — Examinations  should  always  include  both  kidneys,  the 
course  of  the  ureters  and  the  bladder.  Suspicious  shadows  and  most 
positive  findings  should  be  checked  up  with  a  second  examination 
on  another  day.  This  work  requires  plates  of  the  best  technical 
quality.  Any  evidence  of  respiration  or  other  motion  on  a  roent- 
genogram should  cause  its  rejection.  Plates  of  the  bladder  area 
should  be  made  in  both  anteroposterior  and  postero-anterior  posi- 
tions. The  ideal  plate  should  be  of  moderate  density,  thin  rather 
than  over-exposed  and,  as  Leonard  pointed  out  long  ago,  should 
show  clearly  the  last  two  ribs,  the  transverse  processes  of  the 
vertebrae  and  the  margin  of  the  psoas. 

THE  KIDNEYS. 

The  normal  kidney  is  of  the  familiar  form,  in  length  approximately 
equal  to  three  vertebral  bodies — the  twelfth  thoracic  and  first  and 
second  lumbar — and  of  smooth,  regular  contour.  The  right  lies 
1  to  2  cm.  lower  than  the  left,  and  is  less  frequentl}'  seen.  "S'isibility 
depends  upon  the  amount  of  fat  around  it.  Kidneys  are  not  particu- 
larly movable  in  the  normal  individual.  At  the  most  they  will 
drop  not  over  1  cm.  in  the  change  from  the  supine  to  the  standing 
position.  In  young  children  they  are  lower  than  in  adults.  The}' 
lie  close  to  the  margin  of  the  psoas  and  are  crossed  by  the  shadows 
of  the  last  two  ribs. 


192 


GENITO-URINARY  TRACT 


Changes  in  size  of  the  kidneys  are  not  diagnostic.  The  shadow 
may  have  been  distorted  or  enlarged  by  the  size  of  patient  or  posi- 
tion of  tube;  or  a  kidney  may  be  hypertrophied  as  a  result  of  disease 
in  its  fellow,  while  on  the  other  hand,  the  shadow  may  be  of  normal 
size  but  the  kidney  be  badly  damaged. 

Changes  in  shape  are  due  to  tumors,  cysts,  or  infections  and 
anatomical  variations.  They  may  be  found  in  the  pelvis,  they  may 
fuse  across  the  vertebrae,  there  may  be  only  one  kidney  present 
and  an  additional  ureter  may  be  attached  to  a  kidney. 


Fig.  167. — Position  and  outline  of  normal  kidneys,  v/ith  the  patient  standing. 


Changes  in  density  will  be  found  extremely  luireliable  in  diag- 
nosis. While  it  is  true  that  in  rare  eases  tuberculosis  of  the  kidney 
may  be  suspected  from  the  presence  of  a  mottled  shadow  of  increased 
density,  in  general,  mottling  will  be  found  to  be  due  to  intestinal 
contents.  The  principal  value  of  the  roentgen  examination  lies 
in  the  detection  of  stone.  In  good  hands,  probably  SO  to  90  per 
cent,  of  all  kidney  and  ureteral  (not  bladder)  stones  will  show. 
Their  visibility  depends  upon  the  technic,  preparation  and  size  of 
patient  and  the  composition  and  size  of  the  stone.    The  first  two 


THE  KIDNEYS 


193 


factors  may  be  controlled  by  repeated  examinations  and  in  regard 
to  the  last  point,  the  order  of  visibility  is  as  follows:  phosphates 
and  cystine  very  dense,  oxalates  next  and  urates  last,  which  have 
little  if  any  greater  density  than  that  of  the  soft  tissues.  Stones 
which  lie  in  large  inflamed  kidneys  may  be  so  obscured  by  the 
general  density  about  them  that  they  are  not  visible.  Furthermore, 
the  shadow  of  a  stone  may  overlie  a  rib  or  transverse  process  and 


Fig.  U 


-Tuberculosis  of  the  kidney.     The  shadow  of  the  enlarged  kidney  can  be 
indistinctly  seen.     There  is  a  small  stone  in  the  upper  calix. 


be  overlooked.  It  sometimes  happens  that  a  stone  previously 
invisible  will  receive  a  coating  of  thorium  during  pyelography  and 
become  evident.  They  usually  occur  in  the  region  of  the  pelvis 
and  lower  calices..  They  may  be  round,  although  they  are  usually 
irregular  and  sometimes  assume  the  form  of  a  cast  of  the  pelvis  in 
which  they  are  located.  It  must  not  be  forgotten  that  a  single 
shadow  may  represent  multiple  stones.  Discrete  shadows  scattered 
through  the  periphery  of  the  kidney  shadow  suggest  a  kidney  dis- 
13 


194 


GEN  I  TO-URINARY  TRACT 


Fig.  169. — Large  branching  calculi  in  both  kidneys. 


Fig.  170. — Unusual  type.s  of  kidney  stones.  The  faceted  atones  in  the  right  suggest 
gall-stones,  but  the  position  and  -nide  curve  of  the  catheter  prove  they  are  in  the 
kidney  pelvis. 


THE  KIDXEYS  195 

tended  by  back  pressure  with  stones  separated  by  fluid.  Large 
dendritic  stones  mean  that  the  kidney  has  suffered  severely. 

Shadows  which  may  be  confused  with  stones  are:  (1)  those  due 
to  material  in  the  bowel,  fecal  masses,  fruit  pits,  enteroliths,  opaque 
salts,  such  as  bismuth  and  barium  (particularly  residues  in  diver- 
ticulse  of  the  colon),  Blaud's  pills,  salol  capsules.  The  appendix 
often  lies  in  close  relation  to  the  right  ureter  and  foreign  bodies 
or  enteroliths  within  it  may  be  mistaken  for  ureteral  calculi.  (2) 
Gall-stones  which  can  usually  be  differentiated  by  their  structure 
and  shifting  position  with  reference  to  the  kidney  area  on  plates 
taken  in  the  anteroposterior  and  postero-anterior  diameters.  (3) 
Calcified  glands  which  have  a  spongy  appearance  usuallv  sufficient 
to  identify  them.  They  occur  along  the  course  of  the  root  of  the 
mesentery,  in  a  line  from  the  left  kidne}"  to  the  anterior  right  sacro- 
iliac, and  in  the  neighborhood  of  the  iliac  vessels,  differentiated  by 
shifting  position.  (4)  Tuberculous  foci  in  the  kidneys  may  calcify 
and  give  shadows  resembling  those  of  stone.  (5)  Calcification  in 
carcinomatous  masses  in  the  pancreas  or  glands  may  be  a  rare  cause 
of  confusion.  (6)  The  tip  of  a  transverse  process  may  be  so  much 
more  dense  than  the  rest  of  it  that  it  may  suggest  a  stone.  (7) 
Small  areas  of  density  in  the  spleen  may  overlie  the  upper  portion 
of  the  kidney.  (8)  Calcification  in  a  blood  clot  or  about  a  foreign 
body  may  simulate  a  stone  if  it  overlies  the  kidncA'.  (9)  Mention 
must  also  be  made  of  the  shadows  cast  by  fibromata,  scars  and  even 
dressings  on  the  back  which  may  be  recorded  on  the  plate  as  areas 
of  increased  density.  (10)  Artefacts  in  plates  due  to  thin  spots  m 
the  emulsion  or  small  areas  which  are  unequally  dcA'eloped  may  be 
a  source  of  confusion. 

Pyelography. — Pyelography  is  not  a  procedure  to  be  undertaken 
without  due  consideration  and  caution.  SeA'ere  reactions  cannot  be 
entirely  avoided  although  a  careful  technic  will  do  much  to  prevent 
them.  The  most  important  single  precaution  to  be  obserA'ed  is  to 
allow  the  solution  to  flow  in  very  slowly  under  a  slight  gravity 
pressure  and  to  stop  as  soon  as  the  patient  complains  of  pain  in 
the  kidney.  Perhaps  the  best  medium  to  use  is  a  15  per  cent. 
thorium  solution,  as  it  is  cleaner,  more  fluid  and  less  toxic  than  the 
silver  salts. 

The  outline  of  the  kidney  pelvis  as  obtained  by  this  method 
varies  greatly.  The  normal  pelvis  is  somewhat  lily-shaped  with 
the  ureter  corresponding  to  the  stem.  The  pelvis  presents  a  more 
or  less  rounded  border,  into  which  the  ureter  blends  on  the  inner 


196 


GEN  I  TO-URINARY  TRACT 


Fig.  171. — Large  stone  in  the  urinary  bladder. 


Fig.  172. — Injected  kidney  pelvices.     The  abnormal  shape  is  due  to  anatomical 

variation. 


THE  KIDNEYS  197 

margin.  Arising  from  its  outer  edge  are  a  variable  number  of  pro- 
cesses projecting  into  the  kidney  substance  (the  major  calices)  from 
the  tips  of  which  arise  small  further  projections  called  minor  calices, 
(with  cupping  between).  The  pelvis  may  be  more  or  less  globular 
or  consist  entirely  of  two  or  more  branches.  The  errors  which  must 
be  guarded  against  are  incomplete  filling  of  the  pelvis,  usually  due 
to  spasm  of  the  ureter  or  pelvis  brought  on  by  too  rapid  disten- 
tion, compression  from  neighboring  organs,  extrarenal  tumors  and 
rotation  of  the  kidnev. 


Fig.  173. — Hydronephrosis,  demonstrated  by  injection  with  thorium. 

Anomalies. — Aberrant  positions  of  the  kidneys  and  multiple 
ureters  are  perhaps  best  brought  out  by  this  method  which  is  more 
accurate  than  plain  roentgenology  with  or  without  opaque  catheter. 

Hydronephrosis. — Hydronephrosis  shows  all  degrees  of  change 
from  blunting  of  the  minor  calices  to  the  formation  of  a  large  sac, 
depending  upon  the  site  of  the  obstruction  and  the  length  of  its 
existence.  With  obstruction  near  the  kidney  the  characteristic 
early  change  is  blunting  of  the  minor  calices.  With  obstruction 
near  the  bladder,  on  the  other  hand,  dilatation  of  the  pelvis  and  a 
certain  amount  of  rounding  of  its  outline  is  the  characteristic  find- 


198 


GEN  I  TO-URINARY  TRACT 


ing.  In  the  later  stages  of  the  process  both  major  and  minor  calices 
may  disappear  and  the  thorium  collect  in  a  pool  in  the  sac  with 
remains  of  the  kidney.  The  discovery  of  a  stone  in  the  ureter  is 
confirmatory  evidence  of  the  process  in  the  pelvis. 

In  inflammatory  conditions  the  chief  change  is  in  the  major 
calices  which  are  apt  to  have  irregular,  moth-eaten  edges  and  to  be 
increased  in  length  and  width.  In  the  later  stages  they  may  show 
rounded  dilatations  at  their  extremities.  The  form  of  the  pelvis 
varies  according  to  the  amount  of  destruction  of  the  kidney  sub- 
stance and  the  amount  of  distention  of  the  pelvis. 


Fig.  174. — The  injected  pelvis  of  an  infected  kidney. 


Tuberculosis. — The  characteristic  change  here  is  lengthening  of 
the  major  calices  with  pronounced  bulbous  dilatation  at  the  tips 
and  the  occurrence  of  rounded  masses  of  thorium  in  the  cortex, 
representing  cavities  communicating  with  the  pelvis.  Stricture  of 
the  ureter  may  prohibit  the  filling  of  the  kidney  pelvis. 

Growths. — Extrarenal  and  parenchymal  tumors  may  cause 
deformities  in  the  pelvis  and  calices  which  are  similar  in  all  respects. 
It  is  not  always  possible  in  the  presence  of  a  distorted  pelvis  showing 
an  irregular  loss  of  calices  to  say  whether  it  is  due  to  incomplete 


URETERS  199 

filling,  extrarenal  tumor  or  a  growth  in  the  cortex.  The  amount  of 
deformity  produced  in  the  pelvis  depends  upon  the  size  and  loca- 
tion of  the  tumor.  A  very  characteristic  picture  is  the  irregular 
prolonged  extension  of  one  or  more  calices  to  a  considerable  distance 
beyond  the  usual  limits  in  a  normal  kidney.  When  the  whole 
kidney  is  involved,  the  pelvis  may  be  reduced  to  a  small  mass  with 
irregular  strands  of  thorium  stretching  out  from  it  in  a  spider-like 
pattern.  Polycystic  kidneys  produce  a  somewhat  similar  picture 
as  well  as  enlargement  of  the  kidney  outline,  but  here  the  defects 
in  the  pelvic  shadow  are  not  so  irregular  and  their  margins  show  the 
rounded  indentations  of  the  neighboring  cysts.  Furthermore,  the 
process  here  is  usually  bilateral.  The  ureter  is  long  and  curves  over 
the  enlarged  lower  pole  of  the  kidney  which  may  extend  far  enough 
inward  to  throw  the  shadow  of  the  ureter  over  the  spine. 

Papillomata. — Papillomata  in  the  pelvis  may  produce  round  holes 
in  the  thorium  shadow.  Stones  in  the  pelvis  or  calices  produce  an 
intensification  of  thorium  shadow  at  that  point. 

URETERS. 

The  course  and  condition  of  the  ureters  may  be  very  well  out- 
lined provided  they  can  be  kept  filled  with  thorium  during  exposure. 
This  may  be  a  somewhat  difficult  matter  in  the  normal  ureter  if  the 
catheter  is  too  small  to  occlude  the  lower  end.  Injection  has  these 
advantages  over  the  use  of  radiographic  catheters:  the  ureter  lies 
in  its  true  course  and  does  not  conform  to  that  of  the  rather  rigid 
catheter,  and  changes  in  diameter  and  irregularities  in  outline  are 
well  brought  out.  Apparent  kinking  due  to  the  angulation  in  the 
ureter  produced  at  the  tip  of  the  catheter  does  not  occur,  whereas 
true  kinks  are  readily  recognizable.  Abnormalities  are  fairly 
common,  as  has  already  been  mentioned,  consisting  of  multiple 
ureters.  Irregularities  in  outline  are  usually  the  result  of  infection, 
most  commonly  of  tuberculous  origin  which  usually  appears  first 
in  the  lower  portions  of  its  course.  Dilatations  may  be  true  diver- 
tlculse  which  contain  stones  or  the  enlargement  above  an  obstruc- 
tion as  a  result  of  pressure  from  tumors  or  adhesions,  the  latter 
being  particularly  common  following  infections  of  the  vas  deferens 
in  the  male  and  pelvic  cellulitis  in  the  female. 

The  course  of  the  ureter  is  downward  across  the  transverse  pro- 
cesses of  the  lumbar  vertebrae  and  sacro-iliac  joints  to  the  pelvis,  then 
curving  inward  and  forward  toward  the  bladder.    There  are  four 


Fig.  175. 


-Small  stone  in  the  lower  end  of  the  ureter.    Its  transverse  position  shows 
that  it  is  near  the  mouth  of  the  ureter. 


Fig.  176. — A  calcified  mesenteric  gland  suggesting  a  stone  in  the  ureter. 


Fig. 


177. — The  same  cvTse  as  Fig.  176.    The  radiofiraphic  fathetcr  demonstrates  that 
the  shadow  is  well  outside  the  course  of  the  ureter. 


Fig.  178. 


-Large  stone  in  dilated  ureter.     The  catheter  is  obstructed, 
ureter  is  made  visible  by  the  injection  of  thorium. 


The  dilated 


202  GENITO-URINARY  TRACT 

points  of  narrowing  where  stones  are  prone  to  lodge:  (1)  the  uretero- 
pelvic  junction,  (2)  where  they  cross  the  ihac  vessels,  (3)  just  out- 
side the  bladder,  (4)  the  papilla  within  the  bladder.  Stones  w^ill 
be  found  most  commonly  at  (1)  and  (3).  They  are  easily  over- 
looked when  lodged  near  the  iliac  vessels,  because  their  shadow  is 
projected  on  to  that  of  the  sacrum.  They  may  be  projected  b}^ 
an  increased  tilt  of  the  tube.  The  shadows  of  ureteral  calculi  are 
oval  or  enlongated  and  are  irregular  in  outline  and  density.  Their 
long  axis  lies  in  the  direction  of  the  course  of  the  ureter.  Shadows 
which  may  be  confused  with  them,  in  addition  to  those  enumerated 
before,  are  h^'pertrophic  changes  upon  the  vertebrae  or  pelvic  bones, 
arteriosclerosis  of  the  pelvic  arteries,  calcified  fibroids,  calcified 
ovaries,  dermoid  cysts  and  phleboliths.  Phleboliths  are  small,  cir- 
cular or  oval,  sharply  outlined  calcifications  usually  multiple,  which 
occur  in  the  pelvis  in  the  region  of  the  ischial  tuberosities.  They 
are  calcified  thrombi  on  the  distal  side  of  the  valves  ia  the  plexus 
of  veins  in  the  pelvic  cellular  tissue  about  the  bladder  and  rectum. 
They  are  very  common  and  are  constantly  being  mistakea  for 
ureteral  calculi.  The  distinguishing  characteristics  of  a  calculus  are 
that  it  is  not  so  sharply  outlined,  that  it  is  more  apt  to  be  oval 
than  round,  and  that  it  lies  in  the  course  of  the  ureter  which  passes 
above  and  internal  to  the  area  where  phleboliths  lie.  Furthermore, 
phleboliths  seldom  occur  singh'. 

In  case  of  doubt  the  patient  should  be  examined  with  an  opaque 
catheter  in  the  ureter,  preferably  stereoscopically,  in  order  to  deter- 
mine the  presence  or  absence  of  obstruction  as  well  as  the  relation 
of  the  suspected  shadow  to  the  ureter. 

BLADDER. 

The  outline  of  the  partially  filled  bladder  may  be  made  out  in 
many  pelvic  plates  but  may  be  readily  visualized  by  filling  it  with 
air  or  dilute  thorium.  Stones  in  the  bladder  are  occasionally  not 
visible  because  a  large  percentage  of  them  are  urates.  Important 
characteristics  of  bladder  stones  are  that  they  are  of  fairly  large 
size,  are  oval,  and  lie  with  their  long  axis  transversely  in  the  pelvis. 

The  bladder  may  be  outlined  by  thorium  (us'ually  10  per  cent.) 
or  by  air.  Large  diverticulse  are  usually  well  brought  out  by 
moderate  distention  with  thorium.  They  appear  as  knobs  on  either 
side  or  behind  the  main  shadow  and  may  be  larger  than  the  bladder 
itself.  Trabeculation  of  the  bladder  wall  is  sometimes  suggested 
by  irregularity  of  the  outline,  particularly  along  the  sides.    In  some 


BLADDER 


203 


Fig.    179.- 


-Diverticulum  of    the  bladder,  demonstrated  by  fillinc 
collargol. 


the  bladder  with 


Fig.  ISO. 


-Diverticulum  of  the  bladder,  demonstrated  by  means  of  the  radiographic 
catheter. 


204 


GEN  I  TO-URINARY  TRACT 


cases,  particularly  of  tuberculosis,  distention  of  the  bladder  may 
cause  the  solution  to  run  up  a  dilated,  irregular  ureter  and  visualize 
it  and  the  kidney  pelvis  when  catheterization  is  impossible.  In 
children  where  it  is  difficult  to  catheterize  the  ureters,  they  may 
sometimes  be  similarly  filled  by  distention  of  the  bladder  in  cases 
of  obstruction  at  the  neck  of  the  bladder  due  to  congenital  valves 
in  the  region  of  the  verumontanum.  Congenital  anomalies  are 
sometimes  encountered,  such  as  hour-glass  bladder  and  patent 
urachus  which  gives  a  thin  line  of  solution  extending  upward  toward 
.the  umbilicus. 


Fig.  181. — Papillomatous  tumor  of  the  bladder,  on  which  there  is  a  deposit  of 

calcium. 


Tumors  may  be  extensive  enough  to  produce  defects  in  the 
thorium  shadow,  although  it  is  unusual.  A  better  method  for  their 
demonstration,  which  is  equally  useful  in  the  case  of  stone,  is  to 
inflate  the  bladder  with  air  and  secure  stereoscopic  plates.  Hyper- 
trophied  prostates  may  be  well  outlined  by  inflating  both  the  bladder 
and  the  rectum  with  air. 


REFERENCES  205 

MALE  GENITALS. 

Small  multiple  calculi  occur  in  the  prostate  and  may  be  mistaken 
for  urinary  concretions.  The  vas  deferens  and  seminal  vesicles, 
when  injected  with  silver  solution,  show  a  certain  amount  of  dis- 
tortion as  a  result  of  vesiculitis.  This  procedure  will  probably 
never  come  into  extensive  use. 


FEMALE  GENITALS. 

Calcification  is  often  seen  in  fibroids  in  the  form  of  round,  irregu- 
larly calcified  masses,  often  multiple  and  occupying  any  portion 
of  the  pelvis.  In  rare  cases  the  ovaries  may  be  calcified.  They  are 
oval,  flattened,  spongy  masses  suggesting  glands  lying  internal  to 
and  above  the  ischium.  They  may  be  mistaken  for  ureteral  stones. 
Attempts  have  been  made  to  inject  the  uterus  and  tubes  with  opaque 
solution  but  the  technic  is  still  undeveloped. 

REFERENCES. 

Cabot,  Hugh:    Modern  Urology,  Philadelphia. 

Beer,  E. :  Relative  values  of  the  roentgen  rays  and  the  cystoscope  in  the  diagnosis 
of  vesical  calculi,  Jour.  Am.  Med.  Assn.,  1913,  Ixi,  p.  1376. 

Braasch:    Jour.  Am.  Med.  Assn.,  October  9,  1915. 

Cabot,  Hugh:    Jour.  Am.  Med.  Assn.,  191.5,  Ixv,  p.  1233. 

Holland:  XVIIth  International  Congress  of  Medicine,  London,  1913,  Section  22, 
Radiologic  P-  ii>  PP-  87-100. 

Keen,  Pfahler  and  Ellis:    Jour.  Am.  Med.  Assn.,  1914,  viii,  p.  1047. 

Dodd,  W.  J.:    Roentgenologj^  of  the  urinary  tract.  Modern  Urology,  Philadelphia. 

Braasch,  W.  I.:    Pyelography,  W.  B.  Saunders  Company,  Philadelphia,  1915. 

Hyman,  A.,  and  Jaches,  L.:  The  roentgenographic  diagnosis  of  pro.static  enlarge- 
ment bj'  means  of  air  inflation  of  the  bladder,  Surg.,  Gvnec.  and  Obst.,  1914,  xix, 
p.  407, 


INDEX. 


Abnormal  fusing  malformations,  32 
Abnormality  of  heart,  congenital,  124 

in  outline  of  vertebrae,  36 
Abscess,  ah'eolar,  91 

bones,  52 

of  lung,  141 

mediastinal,  128 

perivertebral,  128 

subdiaphragmatic,  131 
Absence  of  long  bones,  partial  or  com- 
plete, 20 
Achondroplasia,  78 
Acromegaly,  75 
Actinomycosis  of  the  bone,  62 

of  lung,  149 
Adhesions,  duodenal,  181 

perigastric,  163 

of  pleura,  135 
Alveolar  abscess,  91 
Aneurysm,  125 
Anomalies  of  bones,  29 

of  dentition,  90 

of  genito-urinary  tract,  congenital, 
197 

of  kidnev,  197 

of  ribs,  28 
Anthracosis,  149 
Antispasmodics,  gastric,  161 
Aorta,  diffuse  dilatation  of,  125 
Aortic  cUsease,  124 
Aortitis,  specific,  125 
Appendix,  normal,  182 

pathological,  182 
Arch,  dilatation  of,  124 
Arthritis,  atrophic,  99 

gonorrheal,  101 

hypertrophic,  97 

pyogenic,  100 

villous,  104 
Atomic  colon,  185 
Atrophic  arthritis,  99 
Auricular  fibrillation,  124 


BARirM  meal  for  examination  of  gastro- 
intestinal tract,  152 


Bladder,  diverticute  of,  202 

outline  of,  202 

stones,  characteristics  of,  202 
Bone  abscess,  non- virulent,  52 

virulent  or  fulminating  type, 
52 

blisters  in  sj-phihs,  58 

cysts,  63 

changes  in  density  of,  50 
in  outhne  of,  50 
in  phosphorus  poisoning,  62 

diffuse  density  of,  50 

diminution  in  size  of,  50 

disease  of,  50 

gumma  of,  destruction  due  to,  59 

leprosy  in,  62 

normal,  50 

oidiomycosis  of,  62 

signs  of  pathological  process  in,  34 

spong}^,  areas  of  increased  density 
in,  23 
texture  of,  50 

spotted  density  of,  50 

syphihs  of,  57,  59,  104 
congenital,  59 

tuberculosis  of,  101 

tumors  of,  rarer,  71 

typhoid  in,  61 
Bones,  anomalies  of,  29 

detached,  29 

diminution  in  size  of,  50 

fusion  of,  30 

margins  of,  rovighening  of,  20 

size  of,  increase  in,  50 

supernumerary,  30 
Brain  tumor,  84 

Bronchial  glands,  calcification  of,  21 
Bronchiectasis,  142 
Bronchitis,  141 
Bronchopneumonia,  140 
Bronchostenosis,  143 
Bursae,  calcification  of,  109 


Calcification  of  bronchial  glands   21 
of  bursae,  109 
of  costal  cartilage,  20 
of  larynx,  20 


208 


INDEX 


Calcification  of  mesenteric  glands,  21 
of  ovaries,  205 
of  pineal  glands,  86 
syphilitic,  58 
Calcifications,  20 
Carcinoma  of  cardia,  168 
metastatic,  70 
of  pylorus,  171 
of  skull,  69 
of  spine,  69 

of  stomach,  characteristic  findings 
in,  70 
Carcinomatous  ulcers  of  s'tomach,  170 
Cardia,  carcinoma  of,  168 
Caries  sicca,  56 
Carpal  centers,  time  of  appearance  of, 

32 
Cecum,  change  in  outline  of,  185 

normal,  182 
Chahcosis,  149 
Charcot  joints,  97 

Chest,  glands  of,  enlargement  of,   111 
technic  in  examination  of,  120 
time  of  exposure  for  examination 

of,  121 
tumors  of,  112 
Chondrodystrophy  fetalis,  78 
CoUes'  fracture,  39 
Colon,  atonic,  185 

change  in  motility  of,  185 
in  outline  of,  185 
in  position  of,  185 
in  size  of,  185 
examination  of,  barum  enema  in, 

184 
normal,  183 
spastic,  185 

method  of  examination  by  barium 
enema,  184 
Congenital  abnormality  of  heart,  124 
anomahes  of  genito-urinarv  tract, 

197 
dislocations  of  hip,  48 
elevation  of  scapula,  29 
syphilis  of  bone,  59 
Costal  cartilage,  calcification  of,  20 
Cyst  of  lung,  echinococcus,  147 
Cysts,  bone,  63 
dermoid,  114 


Dactylitis  (spina  ventosa),  56 

(syphihtic),  57 
Defective  plates,  errors  due  to,  25 
Defects  in  outline  of  rectum,  186 
Delayed  union,  32 
Dentition,  anomalies  of,  90 

table  (Thoma),  90 
Dermoid_cysts,  114 


Diaphragm,  changes  in  mobility  of,  129 
in  outline  of,  129 
in  position  of,  130 

normal,  129 
Dilatation  of  ileum,  182 
Dislocations,  before  and  after  reduc- 
tion, 49 

of  first  cervical  vertebra,  45 

of  hip,  congenital,  48 
Displacement  of  sacro-iliac  joint,  47 

of  semilunar  cartilage  in  carpus,  47 

of  upper  cervical  vertebrte,  45 
Diverticulse  of  bladder,  202 
Duodenal  adhesions,  181 

diverticulse,  181 

scars,  180 

spasm,  180 

ulcer,  180 
Duodenum,  defects  in  outline  of,  180 

irregularities  in  outline  of,  180 

normal,  180 
Dysplasia,  periosteal,  78 


E 


Echinococcus  cyst  of  lung,  147 
Elevation  of  scapula,  congenital,  29 
Emphysema,  111 
Empyema,  132 
Encapsulated  fluid,  133 
Enchondromata,  62 
Epiphyseal  ossification,  31 

separations,  47 
Epiphyses,  tuberculosis  of,  53 
Esophagus,  change  in  position  of,  154 

dilatation  of,  128 

diverticulse  in,  158 

examination  of,  152 

pathological,  153 
Extragastric  defects,  163 
Extrarenal  tumors,  198 


Failure  of  union,  32 
Fibromata  of  skin,  24 
Fluoroscopic  examination  of  heart  and 
great  vessels,  118 
of  gastro-intestinal  tract,  151 
of  hmg,  131 
Foreign  bodies  in  lung,  142 

examination  for,  142 
in  stomach,  173 
Fracture,  CoUes',  39 

lines,  obliteration  of,  34 
Pott's,  42 
Fractures,  classification  of,  37 

lines  mistaken  for  (nutrient  artery), 
19 


INDEX 


209 


Fractures  of  skull,  35 

of  teeth,  importance  of  roentgen 
examination  in,  91 
Fragilitas  ossium,  78 
Functional  spasms  (gastric),  161 
Fusion  of  bones,  30 


G 


Gall-bladder,  examination  of,   posi- 
tion for,  186 
pathology  of,  188 
position  for  examination  of,  186 
Gall-stones,  detection  of,  187 
Gangrene  of  lung,  143 
Gas  in  intestinal  tract,  25 
Gastric  antispasmodics,  161 

outline,  significance  of  irregulari- 
ties of,  162 
peristalsis,  changes  in,  164 

normal,  158 
spasm,  160 
Tllcer,  172 
wall,  polypi  of,  178 
Gastro-intestinal  tract,  examination  of, 
method  of,  151 
position  for,  151 
fluoroscopic    examination   of, 

151 
syphihs  of,   radiographic  ap- 
pearance of,  176 
ulcers  of,  penetrating,  176 
perforating,  176 
Gastrojejunal  ulcers,  181 
Genito-urinary    tract,    anomalies    of, 
congenital,  197 
examination    of,    preparation 

of  patient  for.  191 
phlebohths  in,  202 
technic  in  examination  of,  191 
tumors  in,  method  of  demon- 
strating, 204 
Glands  of  chest,  enlargement  of.  111 
Gonorrheal  arthritis,  101 
Gout,  97 
Great  vessels,  examination  of,  114 

normal,  123 
Gumma  of  bone,  destruction  due  to,  59 


Heart,  abnormahty  of,  congenital,  124 
block,  124 
dilatation  of,  124 
examination  of,  114 
fluoroscopic  examination  of,  118 
measurements  of  normal  (Claytor 

and  Merrill),  126 
normal,  123 

14 


Heart,  normal,  measurements  of  (Clay- 
tor  and  Merrill),  126 

valves,  diseases  of,  124 
Hemophilia,  106 
Hemorrhages,  subdural,  85 
Hip,  dislocations  of,  congenital,  48 

fractures,  failure  of  union  in,  45 
Hydrocephalus,  83 
Hydronephrosis,  197 
Hypernephroma,  72 
Hypertrophic  arthritis,  97 
Hypertrophy  of  prostate,  204 


Ileum,  dilatation  of,  182 

normal,  181 
Impacted  teeth,  90 
Intestinal  tract,  gas  in,  25 


Jaw,     osteomyelitis     of,      phosph<:>rus 

poisoning  and,  95 
Jejunum,  normal,  181 

pathological,  183 
Joint  lesions,  symmetrical,  60 
unilateral,  60 

sacro-ihac,  displacement  of,  47 
Joints,  Charcot,  97 

tuberculosis  of,  53 
Juxta-epiphyseal  lesion  in  syphilis,  60 


Kidney,  anomalies  of,  197 
change  in  density  of,  192 
in  shape  of,  192 
in  size  of,  192 
normal,  191 
pelvis,  outline  of,  195 

of  papillomata  in,  199 
tuberculosis  of,  198 
Kidneys,  polycystic,  199 


Larynx,  calcification  of,  20 

Leprosy  in  bone,  62 

Linitis  plastica,  177 

Lipomata,  114 

Lobar  pneumonia,  139 

Lumbar  curve,  exaggerated,  28 

Lumbosacral  junction,  articulation  at, 

variations  in,  28 
Lung,  abscess  of,  141 

fields,  examination  of  position  for, 
131 


210 


INDEX 


Lung  fields,  position  for  examination 
of,  131 
fluoroscopic   examination   of,    131 
foreign  bodies  in,  142 

examination  for,  142 
gangrene  of,  143 
metastatic  malignancy  of,  145 
normal,  132 

pathological  changes  in,  132 
primary  malignancy  of,  144 
syphilis  of,  143 
tuberculosis  of,  135 
miliary  of,  138     • 


M 


Mastoids,  90 
Mediastinal  abscess,'_128 

masses,  111 

tumors,  125 
Mesenteric  glands,  calcification  of,  21 
Metastatic  carcinoma,  70 
Mucoceles,  89 

Multiple  cartilaginous  exostoses,  63 
Myeloma,  72 
Myxoma,  73 


N 


Nutrient  artery,  19 


Odontoma,  95 

Oidiomycosis  of  bone,  62 

Orthodiagraphy,  116 

Os  calcis,  separation  and  delayed  union 

in  epiphysis  of,  48 
Ossification  center  of  tibial  tubercle, 

delayed  union  of,  48 
Osteitis  deformans,  65 

fibrosa,  63 
Osteochondritis     deformans    (Perthe's 
disease),  106 

desiccans,  106 
Osteogenesis  imperfecta,  78 
Osteomalacia,  79 
Osteomata,  62 
Osteomyelitis,  characteristics  of,  51 

of  jaw,  due  to  phosphorus  poison- 
ing, 95 
Osteopsathyrosis,  78 
Osteosarcomata,  67 
Ovaries,  calcification  of,  205 
Oxycephalus,  84 


Facet's   disease  (osteitis    deformans), 
65 


Papillomata  in  kidney  pelvis,  199 
Parenchymal  tumors,  198 
Pericarditis,  adherent,  124 

with  effusion,  124 
Perigastric  adhesions,  163 
Periosteal  dysplasia,  78 

sarcoma,  68 
Periostitis,  syphilitic,  57 
Peristalsis,  changes  in  gastric,  164 

normal  gastric,  158 
Perivertebral  abscess,  128 
Perthe's  disease,  106 
Phleboliths,  22 

in  genito-ui'inary  tract,  202 
Phosphorus  poisoning,  change  of  bone 
in,  62 
osteomyelitis  of  jaw  and,  95 
Pineal  glands,  calcification  of,  86 
Plates  of  symmetrical  parts,  importance 

of,  48 
Pleura,  adhesions  of,  135 

thickening  of,  132 
Pleural  effusion,  130,  132 
Pneumoconiosis,  149 
Pneumonia,  lobar,  139 

unresolved,  141 
Pneumothorax,  132,  133 
Poisoning,  phosphorus,  change  of  bone 
in,  62 
osteomyelitis  of  jaw  and,  95 
Polycystic  kidneys,  199 
Polypi,  89 

of  gastric  wall,  178 
Pott's  fracture,  42 
Prostate,  205 

Prostatic  hypertrophy,  204 
Pulmonary  tuberculosis,  135 
Pulp  stones,  91 
Pyelography,  195 
Pylorus,  carcinoma  of,  171 
Pyogenic  arthritis,  100 
Pyorrhea,  91 


R 


Rectum,  defects  in  outline  of,  186 

normal,  186 

ulceration  of,  186 
Renal  calculus,  detection  of,  192 
Ribs,  anomalies  of,  28 
Rickets,  75 

Roentgen  anatomy,  importance  of,  33 
Round-celled  sarcoma,  67 


Sacro-iliac  joint,  displacement  of,  47 
Salivary  calcuh,  95 
Sarcoma,  periosteal,  68 

round    or    spindle-celled    (medul- 
lary), 67 


m' 


INDEX 


211 


Scapula,  elevation  of,  congenital,  29 
Scars,  duodenal,  180 
Scorbutus,  76 

differential  diagnosis  in,  77 
Sella  turcica,  85 

faulty    technic     in    securing 

views  of,  86 
importance     of     stereoscopic 
views  in  examination  of,  85 
Semilunar  cartilage,  displacement  of,  47 
Seminal  vesicles,  205 
Shadows  due  to  metallic  salts,  25 

in  genito-urinary  tract  other  than 
renal  calcuh,  195,  198 
Sinuses,  frontal,  86 

position  for  examination  of,  86 
variations  of,  89 
Skin,  fibromata  of,  24 

warts  of,  24 
Skull,  carcinoma  of,  69 

fractures  of,  37 
Spasm,  duodenal,  180 

gastric,  160 
Spindle-celled  sarcoma,  67 
Spine,  carcinoma  of,  69 

syphiHs  of,  hypertrophic  changes 

in,  61 
tuberculosis  of,  55 
Stomach  after  gastro-enterostomy,  179 
carcinoma  of,  characteristic  find- 
ings in,  70 
change  in  outhne  of,  160 

in  position  of,  160 
examination  of,  position  for,   156 
foreign  bodies  in,  178 
motility  of,  168 
normal,  156 
pathological,  159 
ulcers  of,  169 

carcinomatous,  169 
Subdiaphragmatic  abscess,  131 
Subdural  hemorrhages,  85 
Supernumerary  bones,  30 
Synovitis,  109 

Syphihs  of  bone,  57,  59,  104 
congenital,  59 
of  gastro-intestinal  tract,    (radio- 
graphic appearance),  176 
juxta-epiphyseal  lesion  in,  60 
of  lung,  147 

of  spine,hypertrophic  changes  in,61 
Syphihtic  calcification,  58 
dactylitis,  57 
periostitis,  57 


Teeth,  90 

fractiires  of,  importance  of  roent- 
gen examination  in,  91 

impacted,  90 

unerupted,  90 
Tele-roentgenology,  1 18 
Teratomata,  112 
Thickening  of  pleura,  132 
Thoracic  wall,  pathological  processes 

in.  111 
Thymus,  enlarged.  111 

normal.  111 
Thyroid,  interthoracic.  111 

normal.  111 
Tibial  tubercle,  separation  of,  48 
Tuberculosis  of  bone,  101 

of  joints  and  epiphyses,  53 

of  kidney,  198 

of  lungs,  135,  138 
mihary,  138 

of  spine,  55 
Tubes  (female  genitals),  205 
Tumors  of  bone,  rarer,  71 

brain,  84 

of  chest,  112 

extrarenal,  198 

mediastinal,  112 

parenchymal,  198 
Typhoid  in  bone,  61 


Ulcer,  duodenal,  180 

gastric,  172 
Ulcers  of  gastro-intestinal  tract,  pene- 
trating, 176 
perforating,  176 
gastro  jejunal,  181 
of  stomach,  169 

carcinomatous,  169 
Unerupted  teeth,  90 
Unresolved  pneumonia,  141 
Ureteral  calculus,  distinguishing  char- 
acteristics of,  202 
Ureters,  course  of,  199 
dilatation  of,  199 
irregularity  in  outline  of,  199 
Uterus,  205 


Vas  deferens,  205 

Vertebra,  first  cervical,  dislocations  of, 

45 
Vertebrae,  upper  cervical,  displacement 

of,  45 
Vertebral  bodies,  extra,  26 
Villous  arthritis,  104 


Table  of  dentition  (Thoma),  90 

of  ossification  centers,  30 
Tabulation  of  findings  in  common  bone 

lesions  for  differential  diagnosis,  80    '  Warts  of  skin,  24 


W 


R^^ 


Hovme-s.        -'.^j-yk     \\u.'=\'^\es 


